
Glass. 
Book 



COPYRIGHT DEPOSIT 



PRACTICAL TREATISE 



ON THE 



DISEASES OF WOMEN 



/ BY 
T. GAILLAKD THOMAS, M. D., LL.D., 

PROFESSOR EMERITUS OF DISEASES OF WOMEN IN THE COLLEGE OF PHYSICIANS AND SURGEONS, 
NEW YORK; CONSULTING SURGEON TO THE NEW YORK STATE WOMAN'S HOSPITAL; 
HONORARY FELLOW OF THE OBSTETRICAL SOCIETY OF LONDON; CORRESPONDING 
FELLOW OF THE OBSTETRICAL SOCIETY OF BERLIN, OF THE OBSTET- 
RICAL SOCIETY OF PHILADELPHIA ; HONORARY MEMBER OF 
THE SOUTH CAROLINA MEDICAL ASSOCIATION, AND OF 
THE GYNECOLOGICAL SOCIETY OF BOSTON. 



SIXTH EDITION, 

ENLARGED AND THOROUGHLY REVISED 
BY 

PAUL FyMUNDE, M.D., 

PROFESSOR OF GYNECOLOGY AT THE NEW YORK POLYCLINIC AND AT DARTMOUTH COLLEGE; 
GYNECOLOGIST TO MT. SINAI HOSPITAL; CONSULTING GYNECOLOGIST TO ST. ELIZABETH 
AND THE ITALIAN HOSPITAL ; FELLOW OF THE AMERICAN, BRITISH, AND GERMAN 
GYNECOLOGICAL SOCIETIES; CORRESPONDING FELLOW OF THE EDIN- 
BURGH AND PHILADELPHIA OBSTETRICAL SOCIETIES, AND OF 
THE GYNECOLOGICAL SOCIETY OF BOSTON, MASS. 

CONTAINING THREE HUNDRED AND FORTY-SEVEN ENGRAVINGS ON WOOD. 




PHILADELPHIA: 

LEA BROTHERS & CO. 



&fc!' 



^ 



^ 



Entered according to Act of Congress, in the year 1891, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress at Washington. All rights reserved. 



Westcott & Thomson, 
Stereotypers and Electrotypers, Philada. 



William J. Doenan, 
Printer, Philada. 



PREFACE TO SIXTH EDITION. 



That the fifth edition of this work has been allowed to be its 
representative' for ten years is not due to lack of solicitation that its 
author should issue a revision, nor yet to his unwillingness to yield 
to pressure exerted from many directions. Unable to find the oppor- 
tunity himself, his choice fell on me as most likely to execute a 
revision in accordance with his own views. While appreciating the 
compliment, I hesitated to accept for two chief reasons : first, the dif- 
ficult nature of the task, which would probably equal if not exceed the 
work of writing an entirely original book of my own ; and secondly, 
the fear that, this being my first venture in the field of revising 
another man's work, I might find it impossible to subordinate my 
own views to those held by the author, and thus either clash with 
him or fail to give proper emphasis to opinions which I did not hap- 
pen to share. The author very kindly obviated these difficulties by 
empowering me to change, omit, or add wherever I saw fit, without 
reference to his views or experience, merely requesting me, when we 
chanced to differ, to state the fact in the text. 

Under these conditions I accepted the task, and have endeavored 
scrupulously to carry out the terms of the agreement. Individual 
experiences or differing opinions have been included in brackets and 
signed T. Gr. T. or P. F. M. as the case may be. All additions and 
alterations in this revision were without exception made by me, and 
I hold myself solely responsible for them. 

In the main, I have tried to be conservative and to avoid advocat- 
ing extreme measures or ideas, which are out of place in a textbook 
designed for students and general practitioners. I have sought so to 
revise and remodel it as to bring not only its general arrangement 



4 PREFACE. 

but also the details of the individual subjects up to date, embodying 
as thoroughly as space would allow the advances and improvements 
made since the publication of the last edition ten years ago. At the 
same time, I have endeavored to preserve as far as consistent with 
the purpose the peculiar and distinctive features which have made 
the work so popular for over a quarter of a century. 

The first chapter, entitled " Historical Sketch of Gynecology," was 
left ■ nearly unaltered, being changed only so as to bring it up to date. 
All the other chapters have been largely altered, and several entirely 
rewritten. That on the Perineum I thought best not to change as 
much as I might have done had I felt able to substitute a more intel- 
ligible or practical description of that organ and its lesions for the 
old one of the author. The chapters on Pelvic Cellulitis and Peri- 
tonitis and on Displacements might have been very much condensed, 
but would not then have shown the changes through which these 
subjects have passed during the last decade. Several new chapters 
have been added, such as those on Electricity, Hermaphrodism, Dis- 
eases of the Urethra and Bladder, and the Diseases of the Female 
Breast. 

The series of illustrations has undergone a corresponding change. 
They are mostly new to the book, and at least one-third now appear 
for the first time. To Messrs. William Wood & Co. I am under 
obligations for permission to use a number of illustrations from their 
publications. 

I hope I have succeeded in doing justice to the confidence imposed 
in me by my friend the author, and in producing a revision satisfactory 
to him and the profession. My critics will, I trust, in passing judg- 
ment on this work, take into consideration the difficulties under which 
a man labors, who after an active experience of his own of twenty- 
five years as a writer and practitioner in the same specialty, under- 
takes the task of revising the work of an older teacher and friend. 

PAUL F. MUNDE. 

No. 20 West 45th St., New York, 
October, 1891. 



FROM THE 



PREFACE TO THE FIFTH EDITION 



The author's object has been to write a practical work, not an 
encyclopaedia ; to record views and methods which recommend them- 
selves on account of their merit, not merely of their novelty. So 
rapidly do new things present themselves in this active department 
of medicine, however, that it must be stated that some innovations 
which apparently possess merit have been left unmentioned because 
sufficient time has not elapsed for their trial. 

To the medical profession in America the author would express 
his sincere thanks for numberless acts of kindness, encouragement, 
and courtesy, which have stimulated his ambition to improve a work 
which has met their generous endorsement and lightened the labor 
which has attended his efforts. 

The kindly reception of previous editions of this work in Europe, 
as evidenced by its translation into German, French, Italian, and 
Spanish, has given the author sincere gratification, and he avails 
himself of this opportunity of thanking the translators for the very 
careful manner in which they have performed their work, and the 
uniform courtesy which they have shown to him. 



CONTENTS. 



CHAPTER I. 

PAGE 

Historical Sketch of Gynecology 17 

CHAPTER II. 

The Etiology of the Diseases peculiar to Women 34 

Neglect of Exercise and Physical Development 36 

Excessive Development of the Nervous System 37 

Improprieties of Dress 38 

Imprudence during Menstruation , . . 40 

Imprudence after Parturition 40 

Non-recognition or Neglect of Injuries due to Parturition 42 

Prevention of Conception and Induction of Abortion 42 

Marriage with Existing Uterine Disease 43 

Insufficient Food 44 

Habitual Constipation 44 

CHAPTER III. 

General Considerations upon Uterine Pathology and Treatment . . 47 

Ovaries and Tubes 51 

Peritoneum 52 

Pelvic Fascia and Ligaments 52 

Prognosis in Uterine Affections 52 

Reasons for the Frequency of Failure in the Treatment of Uterine Diseases . 53 

CHAPTER IV. 

General Considerations upon some of the most Important Therapeu- 
tic Resources of Gynecology 57 

General System of Diet and Exercise 57 

Pessaries 58 

Precautions to be Observed in Operations 60 

Vaginal Injections 64 

The Tampon 67 

Means for Controlling Temperature 69 

CHAPTER V. 

Diagnosis of the Diseases of the Female Genital Organs 71 

Rational Signs 73 

Management of Patient during Physical Examination 75 

Means of Physical Diagnosis 77 

Anaesthesia 77 

Inspection 78 



8 CONTENTS. 

PAGE 

Vaginal Touch 78 

Conjoined Manipulation, or Bimanual Palpation 79 

Abdominal Palpation 80 

Abdominal Palpation conjoined with the Use of the Sound 81 

Digital Eversion of the Rectum 82 

Vesico-rectal Exploration 82 

The Speculum 83 

The Uterine Sound 90 

Tents 93 

The Dull Curette 98 

The Exploring Needle . 99 

The Aspirator 99 

The Microscope 100 

Auscultation and Percussion 101 

Recapitulation of Means for Exploring Pelvic Viscera and Tissues .... 101 

CHAPTER VI. 

Electricity as a Therapeutical Agent in Gynecology 102 

Use of the Faradic Current '. 103 

The Constant Current 104 

Diseases in which Galvanism is Indicated 106 

CHAPTER VII. 

Congenital and Infantile Malformations of the Female Sexual 

Organs; Hermaphrodism 109 

Development of Generative Organs 110 

Hypertrophy 113 

Absence and Rudimentary Development of Uterus and Ovaries 113 

Unicorn, Bicorn, Double, and Divided Uterus . 116 

Congenital Displacement of the Uterus 117 

Absence and Rudimentary State of the Ovaries 117 

Absence and Rudimentary State of Vagina 118 

Short Vagina 118 

Anomalies of Uterine Development during Childhood 118 

Hermaphrodism 119 

CHAPTER VIII. 

Diseases of the Vulva . 123 

Normal and Applied Anatomy . 123 

Deformities of the Vulva 126 

Neoplasms of the Vulva - 127 

Vulvitis 129 

Simple Vulvitis , 129 

Purulent Vulvitis 130 

Adhesive Vulvitis 131 

Follicular Vulvitis 132 

Eruptive Diseases of the Vulva 134 

Phlegmonous Inflammation of the Labia Majora 135 

Rupture of the Bulbs of the Vestibule 136 

Pudendal Hemorrhage 137 

Pudendal Hematocele 13S 

Pudendal Hernia 140 

Hydrocele 141 



CONTENTS. 9 
CHAPTER IX. 

PAGE 

Pruritus Vulvae 143 

Hyperesthesia of the Vulva 150 

Irritable Urethral Caruncle . 151 

Urethral Venous Angioma 154 

Prolapsus Urethras 154 

Cyst and Abscess of the Vulvo-vaginal Glands 155 

Coccygodynia 157 

CHAPTER X. 

The Female Perineum: its Anatomy, Physiology, and Pathology . 160 

CHAPTER XI. 

Prolapse of Vagina, Bladder, Rectum, and Intestines 170 

Prolapse of the Vagina 170 

Cystocele, or Prolapse of the Bladder , 173 

Rectocele, or Prolapse of the Rectum 174 

Enterocele, or Prolapse of the Intestines .... 175 

Treatment of Vaginal Prolapse and Hernias 176 

Colporrhaphy or Elytrorrhaphy 178 

CHAPTER XII. 

Surgical Means adapted to Restoration op the Perineal Body . . . 185 

Varieties of Perineal Laceration 188 

Time for Operation 190 

Treatment of Cases which have Cicatrized 193 

Operation for Partial Rupture 195 

Operation for Complete Rupture 200 

Emmet's New Operation for Lacerated Perineum 204 

Flap-splitting Operation for Lacerated Perineum 205 

Dangers and Evil Results of Secondary Perineorrhaphy 208 

CHAPTER XIII. 

Malformations and Diseases of the Hymen . 209 

Malformations 211 

Absence of the Hymen 211 

Imperforate Hymen 211 

Unyielding Hymen 212 

Hymen with Double Opening . 212 

Fimbriated Hymen 212 

Distensible Hymen 212 

Injuries to the Hymen 212 

Neoplasms of the Hymen 213 

Vaginismus 213 

CHAPTER XIV. 

Vaginitis 216 

Simple Vaginitis .217 

Specific Vaginitis, or Gonorrhoea . 220 

Granular or Papillary Vaginitis 222 



10 CONTENTS. 

CHAPTER XV. 

PAGE 

Atresia of the Genital Tract, and Retention within it of Menstrual 

Blood and Other Fluids 225 

Stenosis and Atresia of the Vagina 226 

Stenosis and Atresia of the Uterus 229 

Operative Procedures 231 



CHAPTER XVI. 

Diseases of the Female Urethra, Bladder, and Ureters 235 

Diseases of the Urethra - 236 

Caruncles and Prolapsus of the Urethra 236 

Urethritis 236 

Urethrocele 237 

Fissure of the Urethra , 238 

Irritable Urethra 238 

Stricture of the Urethra 239 

Diseases of the Bladder 239 

Catarrh of the Bladder ; Cystitis ' 239 

Contraction of the Bladder 241 

Incrustation of the Bladder 242 

Stone in the Bladder 242 

Sloughing of the Mucous Membrane of the Bladder 243 

Cancer and Other Neoplasms of the Bladder 243 

Ureters 244 



CHAPTER XVII. 

Fistulje of the Female Genital Organs 245 

Urinary Fistula? 245 

Vesico-vaginal Fistula 245 

Urethro-vaginal Fistula 245 

Vesico-uterine Fistula? 246 

Vesico-utero- vaginal Fistula? 246 

Treatment 255 

Cauterization 255 

Suture 256 

Sims's Operation 256 

Simon's Operation 261 

Elytroplasty 268 

Closure of the Vagina 268 

Urinary Fistula? requiring Special Treatment 271 

Vesico-cervical Fistula? 271 

Vesico-utero-vaginal Fistula? 271 

Fistula? with Extensive Destruction of the Base of the Bladder 272 

Uretero-uterine and Uretero-vaginal Fistula? 272 



CHAPTER XVIII. 

Fecal Fistula 274 

Entero-vaginal Fistula? 276 

Simple Vaginal Fistula? 276 



CONTENTS. 1 1 

CHAPTER XIX. 

PAGE 

Acute Endometritis , . 277 

CHAPTER XX. 

Chronic Cervical Endometritis 284 



CHAPTER XXI. 

Chronic Corporeal Endometritis 292 

Injections into the Uterine Cavity 301 

CHAPTER XXII. 

Areolar Hyperplasia of the Uterus — the so-called Chronic Paren- 
chymatous Metritis 306 

CHAPTER XXIII. 

Granular and Cystic Degeneration of the Cervix Uteri 329 

Granular Degeneration of the Cervix 330 

Cystic or Follicular Degeneration of the Cervix 334 



CHAPTER XXIV. 

Syphilitic Ulcer of the Cervix Uteri 336 

CHAPTER XXV. 

Uterine Fungosities 338 

CHAPTER XXVI. 

Laceration of the Cervix Uteri 345 

Trachelorrhaphy 353 

CHAPTER XXVII. 

General Considerations on Displacements of the Uterus 358 

CHAPTER XXVIII. 

Ascent and Descent of the Uterus 377 

Ascent of the Uterus 377 

Descent or Prolapsus of the Uterus 378 

Methods of Replacing the Uterus 389 

Methods of Sustaining the Uterus 390 

Pessaries 395 

CHAPTER XXIX. 

Anterior Displacements of the Uterus 400 

Anteversion 400 

Anteflexion 404 



12 CONTENTS. 

PAGE 

Treatment of Anterior Displacements 407 

Means for Reduction 407 

Means for Eetention of the Uterus in Position 409 

Pessaries 412 

Intra-uterine Stems 416 

Operation for Irreducible Cervical. Corporeal, or Cervico-corporeal Flexion . 418 



CHAPTER XXX. 

Posterior Displacements oe the Uteres 422 

Retroversion aud Retroflexion 422 

Methods of Reduction 427 

Methods for Retaining the Uterus in Position 430 

Pessaries 433 

Latero-flexion 441 

CHAPTER XXXI. 

Inversion of the Uterus ■ 441 

Methods of Checking Hemorrhage, the Uterus being Left in situ 450 

Methods of Replacing the Uterus 451 

Gradual Reduction 453 

Rapid Reduction 455 

Methods of Amputating the Uterus 459 

Hernia of the Uterus — Hysterocele 463 

CHAPTER XXXII. 

Para-uterine Cellulitis 4G3 

CHAPTER XXXIII. 

Pelvic Peritonitis 475 

CHAPTER XXXIY. 

Pelvic Abscess 493 

Methods of Operating • 498 

Means for causing Closure of the Sac 499 

CHAPTER XXXV. 

Pelvic Hematocele 500 

Methods of Operating 511 

CHAPTER XXXYI. 

MVO- FIBROMATA, OR FlBROID TUMORS OF THE UTERUS 512 

Palliative Treatment 523 

Curative Medicinal Means 524 

Curative Surgical Procedures 526 

Laparotomy, or Abdominal Hysterectomy . 532 

Myomectomy 540 

Oophorectomy for Fibroid Tumors 541 

Fibro-cvstic Tumors of the Uterus 543 



■■ ■ ■ ■ 



CONTENTS. L3 

CHAPTER XXXVII. 

PAGE 

Uterine Poeypi 546 

Glandular Polypi 547 

Fibrous Polypi 551 



CHAPTER XXXVIII. 

Adenoma and Sarcoma of the Uterus 556 

Adenoma 556 

Sarcoma 558 

Sarcoma of the Pelvic Cellular Tissue 561 



CHAPTER XXXIX. 

Cancer of the Uterus 562 

Epithelioma 564 

Encephaloid 565 

Scirrhus 565 

Surgical Procedures 579 

Palliative Treatment 589 

Complications of Cancer with Other Tumors of the Sexual Organs .... 595 

Fibroids 595 

Ovarian Tumors 595 

CHAPTER XL. 

Disorders of Menstruation 596 

Amenorrhea 600 

Menorrhagia and Metrorrhagia 607 

Curative Treatment 613 

Dysmenorrhea 615 

Neuralgic Dysmenorrhea 616 

Congestive or Inflammatory Dysmenorrhea 619 

Obstructive Dysmenorrhea 620 

Operation 626 

Ovarian Dysmenorrhea 632 

CHAPTER XLI. 

Diseases of the Ovaries 636 

Absence 642 

Imperfect and Irregular Development 642 

Atrophy 647 

Apoplexy or Hematoma 648 

Displacement 650 

Oophoritis . . 652 

Acute 652 

Chronic 655 

Abscess of the Ovary 60S 

CHAPTER XLII. 

Ovarian Tumors 660 

Carcinoma 062 



14 CONTENTS. 



Sarcoma ; 664 

Papilloma 664 

Fibroma 665 

Cysto-carcinoma qqq 

Cysto-sarcoma 667 

Dermoid Cysts 667 



CHAPTER XLIII. 

Ovarian Cysts 672 

Spontaneous Cures of Ovarian Cysts 683 

Solid Abdominal Tumors resembling Ovarian Tumors 690 

Abdominal and Pelvic Cysts resembling Ovarian Cysts 691 

Aspiration 705 

Tapping 706 



CHAPTER XLIV. 

Ovariotomy 708 

Abdominal Ovariotomy . 717 

Irremovable Cysts 744 

Intraligamentous Cysts 745 



CHAPTER XLV. 

Oophorectomy ......... 747 

CHAPTER XLVL 

Diseases of the Fallopian Tubes 751 

Malformations of the Tubes 753 

Tumors 753 

Inflammation of the Tubes 753 

Distortion and Stricture 758 

Hydro-salpinx 759 

Hemato-salpinx 760 

Pyo-salpinx 761 

Laparotomy for Diseased and Adherent Tubes 763 

Palliative Treatment 766 

Other Diseases of the Tubes 767 

Papilloma of the Tube 768 

CHAPTER XLVII. 

Extra-uterine Pregnancy 768 

CHAPTER XL VIII. 

Diseases of the Uterine Ligaments 782 

Diseases of the Broad Ligaments 782 

Diseases of the Utero-vesical and Utero-recto-sacral Ligaments 785 

Diseases of the Round Ligaments •> 785 



CONTENTS. 15 

CHAPTER XLIX 

PAGE 

Sterility 786 



CHAPTER L. 

Diseases of the Female Mammary Glands 794 

Inflammation of the Breast (Mastitis) 796 

Tumors of the Breast 800 

Malignant Tumors 802 



THE 



DISEASES OF WOMEN 



CHAPTER I. 

HISTORICAL SKETCH OF GYNECOLOGY. 

At the present day, when so much attention is being paid to the 
diseases peculiar to women, it becomes almost necessary that a chapter 
upon the history of the subject should precede others of a more prac- 
tical character in a systematic work. A knowledge of what has been 
accomplished in reference to any subject, and what was known concern- 
ing it in previous ages, cannot fail to interest the student and render 
him more capable of appreciating recent advances. In this way, too, 
a taste for the study of ancient literature may be inculcated, and many 
a useful hint, many a suggestive statement, may be met with which 
will germinate for the common good. Some of the most valuable con- 
tributions to modern gynecology will be found to be foreshadowed, or 
even plainly noticed, by the writers of a past age, and afterward entirely 
overlooked. As examples may be be cited the use of the uterine sound, 
sponge-tents, dilatation of the constricted cervix, and even the speculum 
itself. Indeed, we need not seek in ancient literature for illustrations 
of this fact, for nowhere could a more striking one be found than that 
of so valuable a procedure as Sims's operation for vesico-vaginal fistula 
being fully described in every detail in in 1834, and so completely for- 
gotten in twenty years as to be accepted as entirely new at the end of 
that time. 

There can be no doubt that a knowledge of medicine was possessed 
by the ancient Egyptians, whose literature has only within the last 
century been opened to profitable investigation. Until 1799 all con- 
cerning it was enshrouded in darkness. At that time a French 
engineer, while throwing up earthworks at Rosetta, discovered an 
insignificant-looking stone, which has since furnished the wanting key, 
its inscription being written in Greek as well as in the ancient hiero- 
glyphics. Since then valuable papyri have been, thanks to the 
researches of De Sacy, Akerblad, and Champollion, fully and satisfac- 
torily deciphered. The data thus obtained carry the knowledge of 
medicine back to a period previous to three thousand years before 
Christ, and evince an attempt at rational treatment, Egyptologists 

2 17 



18 HISTORICAL SKETCH OF GYNECOLOGY. 

declare, which surpasses that displayed by the early Greeks. The 
"Papyrus of Berlin," the earliest record of medicine, is singularly free 
from superstitious doctrines and use of charms in the treatment of 
disease, which at a later period crept in. Pliny informs us that in the 
times of the Ptolemies a medical school was established at Alexandria 
and dissections of the human body legalized. The Eg}*ptians appear 
to have been especially skilful as oculists, and it is probable that atten- 
tion was paid to the diseases of women, for among the six medical books 
in the collection Thoth, consisting of forty-two volumes, one devoted to 
this subject is particularly mentioned. Some modern Egyptologists 
have even stated that among the hieroglyphics the shape of the uterus 
can be recognized. But Egyptology is certainly to-day only in its 
first infancy. Hope that the future may bring forth a great deal more 
than the past has done with reference to it may be further founded 
upon the fact that Herodotus 1 distinctly announces that specialties 
existed among this primeval people. "Here," says he, "each physi- 
cian applies himself to one disease only, and not more. All places 
abound in physicians — some for the eyes, others for the head, others for 
teeth, others for the parts about the belly, and others for internal 
diseases." 

From biblical literature, which is so abundantly at our command, 
we learn almost as little upon our subject ; and from the time of Moses, 
about 1500 b. c, to that of Hippocrates, 400 b. c, testimony of pre- 
cise knowledge upon it is almost entirely wanting. This is the more 
astonishing when we bear in mind that in the Talmud are found evi- 
dences of a great deal of knowledge concerning the Cesarean section 
and other subjects in obstetrics ; that in the books of Moses we find 
intelligent reference to the hymen and menstruation ; and that in the 
New Testament we see St. Luke, a physician of the time, recording 
the fact of "a woman having an issue of blood twelve years, which 
had spent all her living upon physicians, neither could be healed of 
any," etc. 

Although we know so little concerning the knowledge possessed 
upon this subject by those who preceded the Greeks in civilization, we 
cannot doubt that they did much to instruct the latter in this as in 
other departments of learning. History everywhere records the fact 
that the Greeks were instructed by the Egyptians, as the Romans 
subsequently were by the Greeks. 

With our present knowledge of the literature of the most ancient 
civilizations we must admit that with the writings of the Greek School, 
founded by Hippocrates, commences the history of gynecology. Three 
volumes were written upon the subject by authors contemporaneous 
with Hippocrates. They have ordinarily been attributed to him, but 
Dr. Francis Adams, the translator of the works of Hippocrates for the 
Sydenham Society, declares them to be "ancient, but spurious, whose 
author is not known." In these books the subjects of metritis, indu- 
ration, menstrual disorders, displacements, etc. are discussed. Aretaeus, 
Galen, Archigenes, and Celsus, who probably lived in the first and 
second centuries, all treated of gynecology, the first describing the 

1 Book ii. c. 84. 



HISTORICAL SKETCH OF GYNECOLOGY. 19 

vaginal touch, the varieties of leucorrhoea, and ulceration of the womb ; 
while the second makes the first allusion on record to the speculum 
vaginae as being a distinct instrument from the speculum ani; 
and the third gives a description of peri-uterine cellulitis which shows 
him to have been at least familiar with the fact that the tissues imme- 
diately connected with the uterus were liable to suppurative inflamma- 
tion, the purulent products of which discharge themselves through 
the vagina or rectum. 

Soranus the Younger made important contributions to gynecology. 
He was educated at Alexandria, and went, to Rome in the year 220 
B. c, where he wrote his celebrated work Be liter o et Pudendo Mulie- 
bri. He is the oldest historian of medicine and the biographer of 
Hippocrates. His accurate descriptions of the sexual organs were much 
admired. He takes pains to assure his readers that he dissected the 
human cadaver, and not monkeys, as did Galen and others. He com- 
pared the form of the uterus to a cupping-glass, showed the relation of 
this viscus to the ilium and sacrum, and made known the changes which 
the os undergoes during pregnancy. He attributes procidentia to a 
separation of the internal membrane of the uterus, speaks of the sym- 
pathy which exists between the womb and the mammary gland, and 
describes the hymen and clitoris. He understood digital exploration 
and the use of the uterine sound and vaginal speculum. Many of the 
ancient writers confounded the uterus with the vagina ; he distinguished 
the one from the other very clearly. Soranus likewise differentiated 
pregnancy from ascites and solid tumors, and laid stress upon the 
absence of tympanites and fluctuation of solid tumors as a means of 
distinguishing them from ascites, in which they are present. 

From this time, for centuries, there is abundant evidence that the 
study of the subject was pursued with vigor, but so many of the works 
of the authors of those periods exist only in fragments, and so many 
are strongly suspected of being fictitious, that we pass them over to 
stop at the faithful compilation of Aetius, 1 who flourished at Alexan- 
dria in the sixth century after Christ. His works, compiled in the 
great library at Alexandria, contain a digest of what was known and done 
by his predecessors and contemporaries, and offer the fullest and most 
reliable evidence concerning the knowledge of those times. In quot- 
ing him and his immediate successor, Paulus iEgineta, who was also a 
compiler, though a far less conscientious one, we must be understood as 
recording, not the views of these individuals, but those entertained by 
physicians who lived from the time of Hippocrates to the time of their 
writing, a period of about one thousand years. 

In his sixteenth book Aetius treats of the diseases of women in such 
a manner as to leave no doubt as to his having had a thorough know- 
ledge of many disorders and means of investigation and treatment, 
which, being rediscovered thirteen hundred years afterward, have, in 
many instances, been regarded by us as entirely new. Thus he speaks 
of the speculum, sponge-tents, peri-uterine cellulitis, medicated pessa- 

1 We are indebted to the library of the New York Hospital for an opportunity of fully 
consulting this and other rare works which were accumulated by the late Dr. John 
Watson. 



20 HISTORICAL SKETCH OF GYNECOLOGY. 

ries, vaginal injections, caustics for ulcers of the cervix, dilatation of 
the constricted cervix, a sound for replacing the uterus, etc. 

As we have already stated, Soranus before Christ, and Galen in the 
'second century, speak of the speculum vaginae ; but Aetius still more 
clearly mentions it, and gives rules for its introduction which are copied 
almost verbatim by Paulus without acknowledgment. The use of 
sponge-tents he very fully describes, telling of their mode of prepa- 
ration, and even advising that a thread should be passed through them 
for removal, and that succession of them should be employed till com- 
plete dilatation is accomplished. 1 The importance of injections, the 
douche, hip-baths, and application of caustics for ulcers of the cervix 
he also dwells upon, and advises the dilatation of a constricted cervix 
by means of a tin tube. The variety of vaginal injections in use 
among the Greeks was as great as that of to-day. As astringents, 
pomegranate-rind, galls, plantain, rose oil, alum, sumach, etc. were 
employed, and as emollients, linseed, poppies, barley, etc., exactly as 
we use them now. They relied to a great extent upon the use of med- 
icated pessaries in the cure of ulcerations and inflammatory engorge- 
ments, employing wool covered with wax or butter mixed with saffron, 
verdigris, litharge, etc. Octavius Horatianus even goes so far as to 
advise a mixture of arsenic, quicklime, and sandarach in very foul 
ulcers. In addition to injections and pessaries, Aetius mentions the 
use of vapor, medicated or simple, conducted to the cervix by means 
of a reed passed up the vagina. 

The use of a uterine sound, passed into the uterus and employed as 
a repositor, is likewise alluded to by this author in a passage where he 
advises that displacements of the uterus should be corrected speeillo 
et digito. 

Paul of iEgina, who succeeded Aetius, alludes distinctly to the spec- 
ulum as an instrument in general use before his time. " If, therefore," 
says he, " the ulceration be within reach, it is detected by the dioptra ; 
but if deep-seated, by the discharges." And again : " The person using 
the speculum should measure with a probe the depth of the woman's 
vagina, lest, the tube of the speculum being too long, it should happen 
that the uterus be pressed upon." 

It is curious to see how, even in many minor matters, the ancients 
anticipated discoveries which our contemporaries have brought forward 
as entirely new. For example, the air-pessary, made so popular in 
France and other countries by Gariel, is described and recommended 
by the Greeks. Colombat 2 declares that "the ancient Greek phy- 
sicians made use of pessaries like those just mentioned (air-pessaries), 
of the form and length of the male organ, which is the reason why 
they are called TTptaTicaxTwa, or priapiform pessaries." Albucasis, 
in 1104, describes herpes uterinus ; and uterine hemorrhoids are allu- 
ded to by Paulus iEgineta 3 in this explicit manner : " Hemorrhoids 
form about the mouth and neck of the uterus, which will be discovered 
by the speculum." And thus it is with so many other modern sugges- 

1 Dr. H. G. Wright, Med.-Chir. Rev., lxxi. 

2 Diseases of Females, Meigs's translation, p. 152. 

3 Sydenham Society's edition, vol. i. p. 645. 



HISTORICAL SKETCH OF GYNECOLOGY. 21 

tions that the student of ancient medical literature is most willing to 
admit the truth of the proposition, formulated by Aristotle over two 
thousand years ago, that " probably all art and all wisdom have often 
been already fully explored and again quite forgotten." 

The learning of the Greek School was appropriated by the Roman, 
which was an offshoot from it, as the writings of Celsus, Aspasia, Mos- 
chion, and Antyllus abundantly testify. But the knowledge of the 
schools of Greece and Rome was destined to be scattered abroad. At 
the period of the subjugation of Egypt and the destruction of the cele- 
brated library at Alexandria by the Saracens, A. D. 640, it passed as 
a trophy of war into the hands of the Moslem invaders. "In a few 
centuries the fanatics of Mohammed had altogether changed their 
appearance," says the learned Draper. 1 "When the Arabs conquered 
Egypt their conduct was that of bigoted fanatics ; it justified the accu- 
sation made by some against them, that they burned the Alexandrian 
library for the purpose of heating the baths. But scarcely were they 
settled in their new dominion when they exhibited an extraordinary 
change. At once they became lovers and zealous cultivators of learn- 
ing." The physicians of Alexandria were greeted by them as instruct- 
ors, and from the seed thus planted sprang the Arabian School. With 
other information of course they gained that pertaining to gynecology, 
but, the Mohammedan laws forbidding the examination of women by 
one of the opposite sex, the study languished in their hands ; and 
although Rhazes, Avicenna, and their successors copied from Greek 
writers upon it, a want of zeal, due to want of personal observation and 
experience, allowed a retrograde movement to occur which left the sub- 
ject enveloped in darkness for centuries afterward. Albucasis, one of 
the last of this school, flourished at the end of the eleventh century, 
and after him, although from time to time writers of greater or less 
merit on diseases peculiar to women appeared, nothing worthy of spe- 
cial note occurs, except the occasional allusion to the speculum, which 
had evidently fallen almost entirely into disuse. 

We have, then, sufficient data to warrant the belief that the phy- 
sicians who flourished from the foundation of the Greek School of 
medicine, 400 years before Christ, to the dispersion of the Alexan- 
drian School by the Saracens, 640 years after Christ, were well 
informed in gynecology, and were familiar with means of investigation 
which were subsequently lost or ceased to be appreciated. They fully 
sustain the statement of the English translator of the works of Hip- 
pocrates, that "they furnish the most indubitable proof that the obstet- 
rical art had been cultivated with most extraordinary ability at an 
early period." 

It must not, however, be supposed that the knowledge of the 
ancients was of the same exact and scientific nature as that which has 
prevailed since the modern introduction of the speculum. He who 
seeks in this literature for distinct and lucid pathological data will 
surely meet with disappointment. They did not sufficiently separate 
inflammations of the puerperal and non-puerperal uterus, confounded 
affections of that organ with those of the pelvic areolar tissue, and 
1 Intellectual Development of Europe, p. 285, 



24 HISTORICAL SKETCH OF GYNECOLOGY. 

the length of the uterine cavity in hypertrophy of the cervix, and 
subsequently as an aid to diagnosis by Chanibon, Yigouroux, and 
Desorrnaux. 

As we pass in review the chief works which appeared upon our 
subject in the eighteenth century, we find frequent mention of the 
speculum, which is spoken of as a matter of course in the treatment of 
uterine affections, and yet was evidently not so employed as to render 
it really a valuable aid in diagnosis or treatment. This constitutes one 
of the most curious episodes met with in the history of any discovery 
with which we are acquainted. A most simple and useful instru- 
ment was not only well known in ancient times, and subsequently fell 
into disuse, but fell into disuse without having ever been really forgot- 
ten. It was described by successive writers up to the nineteenth 
century in language as distinct as words could make it, and yet not 
only they who read, but they who wrote it. did not comprehend its 
meaning or appreciate its significance. Like the Indians possessed of 
the diamond, all saw and yet none valued. How could Ambrose Pare, 
for example, writing in 1640, have indicated its use more clearly than 
when he tells us, in chapter xix., that ulcers of the womb may be 
recognized "by the sight or by putting in a speculum'' ? In a copy 
of his works in the library of Dr. W. A. Hammond the word 
"speculum " is italicized in this sentence. Scultetus, as we have seen, 
not only described but figured the instrument in 1683. 

In 1761, Astruc, "Royal Prof, of Physic at Paris." in describing 
occlusion of the vagina and obstruction to the menstrual flow, says : 
i; There is nothing more required than to examine the vagina by intro- 
ducing the finger into it. rubbed previously with oil or pomatum ; but. 
if that be not sufficient, a speculum uteri may be used, or some other 
more simple instrument for dilatation, in order to be able, by means of 
the dilatation of the vagina, to judge by the sight of what the touch 
could not decide." 

In 1801, forty years after this, Recamier is supposed by many to 
have invented the speculum. Most assuredly it was not for the inven- 
tion, but for the regeneration of an instrument which had been curiously 
lost sight of, that the world was indebted to this great man, who was 
really the founder of the modern school of gynecology.. Guided by 
the advice found in many works which his library must have contained 
— works with which to suppose him not to have been perfectly familiar 
would be to cast a slur upon his medical research — he employed a spec- 
ulum vaginae in 1801. Like his predecessors, he did not appreciate the 
great results which were to flow from it, nor does he appear to have 
regarded himself as having invented it. It was not until 1818 that 
he introduced it to the profession and gave it its place as a valuable 
addition to science. Can any one suppose that it could have required 
seventeen years of experimentation and study for a man with the talent 
of Re'camier to have applied this simple and useful instrument to pur- 
poses of utility ? Is it not more likely that the experieuce of seven- 
teen years taught him the full value of the instrument ? The credit 
which belongs to Recamier is not that of an inventor, but that, which 



■ 



HISTORICAL SKETCH OF GYNECOLOGY. 25 

is equally great, of having recognized the value of what was well known, 
but not appreciated by his predecessors and contemporaries. 

Even before this fortunate revival, as the eighteenth century ap- 
proached its close the glimmer of the new era which was about to dawn 
could clearly be detected in the advanced views which were promul- 
gated by Garangeot and Astruc in France, and Denman, John Clark, 
and Hamilton in England. The early part of the nineteenth century 
found the field occupied chiefly by Sir Charles Clarke and Dr. Gooch 
in England, and Recamier and Lisfranc in France. These were not 
the only eminent writers of that time, but they w T ere unquestionably 
those who chiefly moulded professional opinion. 

Even at that period gynecologists divided themselves into two par- 
ties, which may be said to have coalesced only within recent years. 
In England the feeling was strongly in favor of regarding the local 
disorder as the result and not the cause of concomitant constitutional 
derangement, while in France the uterine disease was viewed as the 
main element, and the general condition regarded as dependent upon 
and resulting from it. 

The great advantages of the speculum secured its rapid adoption in 
France. More slowly it forced its way, in spite of many prejudices, in 
Great Britain, and before a great many years had passed it was, through- 
out the civilized world, placed upon an enduring basis as one of the 
many boons bestowed by medicine upon humanity. The way being 
opened for investigation by this instrument, new aids to diagnosis and 
treatment were rapidly brought forward. In 1826, Guilbert read before 
the Academy of Medicine of Paris an essay proposing the application 
of leeches to the cervix. In 1828, Samuel Lair read before the same 
body a paper in which he counselled the use of the uterine sound, which 
had never been utilized. In 1832, M. Melier presented an essay, in 
which he offered two new suggestions in the treatment of uterine dis- 
eases — one, injections into the cavity of the cervix ; the other, local 
applications through the vagina by dossils of lint saturated with astrin- 
gents, narcotics, etc. His views are quoted extensively by French 
writers, and Nonat says that the author recognizes, "avec une fran- 
chise qui l'honore," that Boyle, Chaussier, Guillou, and others had a 
short time before him used similar means. Very curiously, neither 
Melier nor his commentators mention that both these suggestions are 
made and fully elaborated by Astruc in his excellent article upon 
" Ulcers of the Uterus." He describes these applications of medicated 
charpie very carefully, remarking that it is advisable to " tie a thread 
to every pledget, in order to draw it out again when it is proper to 
renew the dressing." And he not only advises injections of water, 
impregnated with different substances, into the cavity of the womb, 
but also the juices of plantain, houseleek, nightshade, etc. "For," 
says he, "as it is of consequence that these injections should enter 
into the uterus, where the ulcer has its seat, it is proper they should be 
made by a professor of midwifery capable of introducing skilfully the 
end of the canula into the orifice of the uterus," etc. 

At this time arose the question as to cancer of the uterus, whether 
it was the local manifestation of a general blood state or the result of 



26 HISTORICAL SKETCH OF GYNECOLOGY. 

an inflammatory engorgement long neglected — a question which excited 
warm discussion and brought forth the most opposite views. 

The ambition of Recamier was not satisfied with exposing the cervix 
uteri to view. He had the boldness to explore the cavity of the body 
of the organ, almost establishing the use of the sound, and even, by 
means of a species of scoop called a curette, ventured in certain cases 
to scrape its investing mucous membrane. In addition, he described, 
through one of his students, pelvic cellulitis, and gave the first intima- 
tion which modern observers have had of the possibility of pelvic 
hematocele. 

The impulse given by Recamier to gynecology cannot be overesti- 
mated, for the instrument which he had rediscovered, and the merits 
of which he had appreciated, was destined to remove it from the field 
of speculation and theory and to place it in that of exact science. 
From about the year 1820 it began to attract general attention and to 
receive the endorsement of the profession. 

The subject at that time received more notice in France than in 
any other country, and for the next twenty years Lisfranc, Boivin, 
Colombat, L'Heritier, Imbert, and others enriched its literature and 
advanced its interests. But it was not until toward the end of that 
time that any really remarkable advance was effected. Then it was 
that Kiwisch in Germany, Huguier in France, and Simpson in Great 
Britain took the lead in their respective countries. 

It has been already stated that from the earliest period of medicine 
the uterine sound had been recommended, and that in the seventeenth, 
the eighteenth, and the nineteenth centuries this recommendation had 
been repeated. In spite of this, it had never become an instrument 
of practical value, and even after 1828, when Lair recommended it, it 
fell entirely out of notice. By a curious coincidence, Kiwisch, Simp- 
son, and Huguier, without concert or communication with each other, 
about the same time urged its adoption, and by vigorous efforts forced 
it upon the attention of all interested in gynecology as a diagnostic 
means of inestimable value. Before this time the sound was practi- 
cally unknown ; after it, it held its place as one of our most valu- 
able diagnostic resources. 

The labors of Recamier marked an era in gynecology. One 
scarcely less important was effected by those of Simpson, who, appear- 
ing in the field about the year 1843, created an enthusiasm for 
the department and gave an impulse to it by the vigor and orig- 
inality of his writings and the brilliancy of his contributions. His 
articles, indeed, first incited the study of uterine displacements in 
Great Britain, and to his efforts may be traced, in great degree, the 
interest which has been of late years aroused in that country with 
reference to uterine pathology. Until this time the subject had 
attracted very little attention there, and advances which had been 
made in it were due almost entirely to French pathologists. It is true 
that the excellent work of Sir Charles Clarke existed, but that warm 
and zealous interest which has since resulted in so much benefit to 
gynecology had not then been excited. But Prof. Simpson was not alone 
in this work. Dr. J. H. Bennet of London, at that time a young 



HISTORICAL SKETCH OF GYNECOLOGY. 27 

physician who had for some years served as interne in the hospitals of 
Paris, returned to his own country imbued with the views which Reca- 
mier and Lisfranc had disseminated among a large circle of followers. 
In 1845 the first edition of his work on Inflammation of the Uterus 
appeared ; and it is safe to assert that no work of modern times, writ- 
ten upon any subject connected with our profession, has exerted a 
more decided and profound influence. Taking up the matter with a 
vigor and energy which forced attention, if not conviction, he pro- 
duced an undeniable impression upon the profession, not only in his 
own country, but in Germany, France, and America. The chief points 
insisted upon in his work are these: 1. That inflammation is the chief 
factor in uterine affections, and that from it follow, as results, displace- 
ments, ulcerations, and affections of the appendages. 2. That men- 
strual troubles and leucorrhcea are merely symptoms of this morbid 
state. 3. That in the vast majority of cases inflammatory action will 
be found to confine itself to the cervical canal, and not to affect the cavity 
of the body. 4. The propriety of attacking the disease in its habitat 
by strong caustics. 

It is now nearly half a century since the appearance of the first 
edition of Dr. Bennet's work, and since during that period his views 
were freely canvassed and vehemently opposed — since, too, his own 
experience had ripened and he had abundant time for more mature 
reflection — it must be a matter of interest to know to what extent his 
opinions were gradually modified. In the London Lancet appeared the 
abstract of a paper read by him before the British Medical Asso- 
ciation in 1870, which served to contrast his more recent with his 
former views. 

The purport of this paper will be best given in the recapitulation 
by which the author concludes it : 

" 1. I consider that, under the influence of mechanical doctrines pushed 
to an extreme, uterine displacements are by many too much studied per se, 
independently of the inflammatory lesions that complicate and often occa- 
sion them. 2. That the examinations made to ascertain the existence of 
inflammatory complications are often not made with sufficient care and 
minuteness, as evidenced by the fact that I constantly see in practice cases 
in which inflammatory lesions have been entirely neglected, and the second- 
ary displacements alone treated. 3. That inflammatory lesions are often 
the principal cause of the uterine displacements through the enlargement 
and increased weight of the uterus, or of a portion of its tissues, which 
they occasion. 4. That when such inflammatory conditions exist, as a rule 
they should be treated and cured, and then time given to nature to absorb 
morbid enlargements before mechanical means of treatment are resorted 
to." 

Soon after the appearance of Dr. Bennet's work a discussion sprang 
up between its author on one side, and Drs. Robert Lee, West, and 
Tyler Smith on the other, with reference to the true character of ulcer- 
ation of the neck, Dr. Bennet supporting the view that the cervix is 
often affected by inflammatory ulceration, and his opponents denying 
it. The importance which he attached to the matter may be appro- 



28 HISTORICAL SKETCH OF GYNECOLOGY. 

ciatecl from the following quotation. In reviewing the state of uterine 
pathology in Great Britain, as illustrated by the standard work of Sir 
Charles Clarke, he says : "Various forms of cancerous ulceration are 
carefully described, but the very existence of inflammatory ulceration 
is not mentioned. Now, when we reflect that, as I shall hereafter 
show, in nearly five cases out of six of confirmed uterine disease, in 
which chronic discharges, mucous, puriform, or sanguinolent, or other 
well-marked uterine symptoms are present, there exists inflammation 
or inflammatory ulceration of the cervix, it is easy to conceive how 
erroneous must be the views respecting uterine pathology of a medical 
school ignorant of so vitally important a circumstance." 

One great advance which was effected by the work of Dr. Bennet 
was the placing upon a surer basis than it had yet occupied the differ- 
entiation of engorgement and induration from commencing cancer of 
the neck. 

It would be well, before proceeding further, to consider very briefly 
the different pathological views which from this time, and even some- 
what before it, were offered to the profession and more or less generally 
adopted. They may be thus enumerated : 

1st. That inflammation is the starting-point of most of the affections 
of the uterus, and that a large number of evils follow this morbid state 
as results. 

2d. That uterine disorder is dependent upon a constitutional derange- 
ment, and would yield without other treatment than that directed to 
the removal of the general condition. 

3d. The view of Dr. Bennet, which is similar to the first mentioned, 
with this additional point, that metritis generally limits itself to the 
neck, and only exceptionally affects the body. 

4th. The view of Dr. Tyler Smith, that leucorrhoea arising from 
glandular inflammation in the cervix is the cause of granular derange- 
ment of this part and of subsequent engorgement. 

5th. The view that uterine disorders often, if not generally, com- 
mence in displacement, which is a primary and not a secondary condi- 
tion, and that to relieve the train of morbid symptoms this, its exciting 
cause, should be first removed. 

6th. The view that uterine disorder is commonly the result of 
ovarian inflammation, which, reacting on the womb, is the prime mover, 
in- many cases, of its morbid states. 

We have no intention of fully discussing here the merits of these 
theories, but will limit ourselves to a few words connected with each. 

The theory mentioned first in this enumeration is the oldest on 
record, the writers of the Greek School, even, adopting it. Thus, 
Paulus iEgineta heads his chapter on the subject, " Inflammation of 
the Uterus and Change of its Position." One of the symptoms of such 
inflammation he considers to be retroversion of the uterus. In the 
beginning of the present century this was generally accepted in France. 
Lisfranc and Recamier adopted it, and it was transferred to and advo- 
cated in Great Britain by the writings of Dr. Bennet. 

No one can devote himself to the practical study of uterine diseases 
without being impressed with the strong grounds which exist for the 



HISTORICAL SKETCH OF GYNECOLOGY. 29 

maintenance of the second of the theories mentioned. No grave ute- 
rine trouble affects the system for any length of time without reacting 
to a greater or less extent upon the general health. The nervous sys- 
tem becomes greatly disordered, the functions under its influence are 
badly performed, and derangement in haematosis is the invariable result. 
As the local disease often approaches stealthily, and may exist for a 
length of time without exciting suspicion, what is more natural than 
that many should view it as one of the numerous results of the general 
depreciation ? These three facts, however, which Avill constantly repeat 
themselves — as often, we may say, as favorable cases offer for testing the 
question — will, we think, very generally lead to a distrust of the doc- 
trine : 1st, The fact that uterine disease and constitutional derange- 
ment existing together, a cure can rarely be effected by general means 
alone ; 2d, that the uterine affection being removed, the general state 
is at once improved ; and 3d, that those general conditions which pros- 
trate the vital forces to the last degree, as, for instance, tuberculosis, 
uraemia, scurvy, leucocythsemia, etc., destroy life without ever showing, 
unless as an exception to a rule, uterine disease as a consequence. 

The constitutional depreciation of a woman will, however, sometimes 
prove a predisposing cause of local disease. As granular degeneration 
under the eyelids will arise from this cause, so will a kindred condition 
often occur on the cervix uteri, yet both will require local as well as 
general treatment. The enfeebled woman is more liable to subinvo- 
lution, passive congestion, and displacements after delivery than the 
strong ; and inflammation of the glands of the cervix is a well-known 
result of phthisis pulmonalis, tertiary syphilis, and anaemia. 

It is a well-accepted fact that an acrid uterine discharge will create 
abrasion of the os, follicular vaginitis, vulvitis, and pruritus, precisely 
as a profuse catarrhal secretion will produce an irritation of the upper 
lip. These conditions are more likely to occur in women with enfee- 
bled constitutions and in those subject to catarrhal inflammation of all 
the mucous membranes. The discovery of a lesion, the significance of 
which we owe chiefly to Dr. Thomas Addis Emmet, has in recent years 
added a new factor to the pathology of uterine discharges and cervi- 
cal erosions, by showing that in women who have borne children these 
pathological conditions are in the majority of cases due to a laceration 
of the cervix produced by parturition. The old theories of Bennet, 
Tilt, Tyler Smith, and others as to the production of many uterine dis- 
eases have, in consequence, undergone many decided modifications, 
and Dr. Emmet's discovery may be said to work a new era in uterine 
pathology. 

We have allowed the preceding views of Bennet, Smith, and Tilt 
to stand substantially unchanged from the last edition, so that the 
reader may see the evolution through which uterine pathology has 
passed during the last fifty years. Practically, these theories may 
now be looked upon as ancient history. 

Some forty years ago the French School, with Velpeau at their 
head, and the profession of this country, led by Hugh L. Hodge o\' 
Philadelphia, accepted the belief that uterine displacements were the 
primary cause of a large majority of the ailments of the female sex. 



30 HISTORICAL SKETCH OF GYNECOLOGY. 

and that the remedy for these ailments lay chiefly in the restoration and 
retention of the uterus in its normal position. In their opinion, the 
engorgement, subinvolution, chronic enlargements, and catarrhs of that 
organ were merely secondary results of the displacement. A more 
recent adherent to these views is Graily Hewitt of London, who, how- 
ever, attached special importance to the distortions or flexions of the 
uterus, rather than to the simple versions. At present the feeling pre- 
dominates that a simple flexion or version of the uterus does not in 
itself produce either local or distant pain or distress, but that it is the 
subinvolution, catarrh, or laceration of the cervix which so very fre- 
quently precedes or accompanies the displacement which causes the 
symptoms of which the patient complains. 

In many women complaining of pelvic pain the ovarian region is 
found to be the seat of the pain, and not the uterus, not only the ova- 
ries, but also the tubes, being found to be prolapsed, enlarged, adhe- 
rent, and exquisitely tender to the touch. The uterus may be per- 
fectly normal, or it may be found retroverted, prolapsed, adherent, or 
otherwise diseased. Of recent years our attention has been called 
more decidedly to the great frequency of disease of the appendages, 
and nowadays no pelvic examination would be complete which omitted 
a careful exploration of those organs. 

Among the first to call attention to the ovaries as a source of pelvic 
pain was Tilt in 1850, and Ritchie at about the same time pointed 
out the occurrence of prolapse of those organs. Tilt ascribed to the 
normal function of the ovaries — namely, ovulation — and their regularly 
recurrent menstrual engorgement a most important role in the produc- 
tion of ovarian disease. He held that morbid ovulation was a most 
frequent cause of oophoritis, and that consequent pelvic peritonitis 
may commonly follow ; further, that subacute oophoritis is very com- 
mon, and not unfrequently causes so-called chronic metritis ; and, 
finally, that disorders of menstruation are very often due to congestions 
and inflammations of the ovaries. 

It is a curious feature that the Fallopian tubes at that time came 
in for almost no share in the etiology of the pelvic pain. Of recent 
observers it is chiefly Lawson Tait to whom the credit is due of having 
first demonstrated the frequency of disease of the tubes, the only too 
common futility of palliative treatment, and the sure and comparatively 
safe cure of the disease by the removal of the diseased organs through 
abdominal section. At the present day, while ovaries are frequently 
congested and inflamed, and while they may become adherent to 
adjacent surfaces of the peritoneum, and while they may become the 
seat of abscess or gradually develop into large, conglomerate tumors 
which are curable only by surgical removal, still, the originally neg- 
lected Fallopian tubes must be admitted to play an equally important 
part in pelvic pathology. According to Noeggerath and some of his 
adherents, the frequency of gonorrhoeal infection of the female is the 
chief reason for the prevalence of tubal diseases. This view is, how- 
ever, not as universally accepted as its promulgators would wish it to 
be, since all candid gynecologists must admit that they are constantly 
meeting with cases of tubal inflammation as a result of exposure to 



HISTORICAL SKETCH OF GYNECOLOGY. 31 

cold, or the spread of a perfectly benign endometritis, or of septic 
infection after abortion or normal parturition, where the suspicion of 
gonorrhceal contagion can be absolutely excluded. 

The first impulse to the remarkable development which has, taken 
place in surgical gynecology since 1850 was given chiefly by four men — 
Recamier in France, Simpson in Great Britain, Simon in Germany, 
and Sims in America. Simpson was the first to introduce chloroform 
as an anaesthetic and to popularize the uterine sound ; Recamier 
invented the uterine curette and reintroduced the tubular speculum ; 
Simon cured the largest vesico-vaginal fistulas and perineal lacerations 
by methods peculiarly his own ; and Sims invented the speculum and 
method of examination now universally known by his name, which has 
revolutionized the modern practice of gynecology. Since their time 
most rapid advances have been made, chiefly in the surgical treatment 
of the diseases of women. Under the lead of Keith, Spencer Wells, 
Barnes, Bantock, Tait in Great Britain ; of Pean, Pozzi, Doleris, 
Courty in France ; of Hegar, Spiegelberg, Schroeder, Martin, and 
Fritsch in Germany ; and of Emmet, Peaslee, Goodell, Battey, Reamy, 
and hosts of younger men in the United States, the severest and most 
dangerous surgical operations on the female genital organs are now per- 
formed with comparative impunity ; removals of ovarian tumors and 
diseased appendages are of every-day occurrence ; lacerations of the 
perineum and cervix, vesico-vaginal fistulae, and distortions of the 
uterine canal are successfully operated on and cured ; the retroflexed 
and prolapsed uterus is stitched to the anterior abdominal wall or sus- 
pended by shortening the round ligaments, etc., and new and ingenious 
operations are constantly devised for the cure of hitherto intractable 
conditions. 

Comparisons are invidious, but we think that the palm will freely 
be given to the Germans for painstaking and laborious researches in 
uterine pathology during the last fifty years. Beginning with the 
Nestors, Kiwisch and Scanzoni, who reigned supreme in the old days 
of medical gynecology, we have to record the names of Veit, Waldeyer, 
Klob, Rokitansky, His, Leopold, Wyder in Germany ; Foulis, Doran, 
Hart, and Barbour in Great Britain ; Bernutz, Goupil, Cornil, and 
De Sinety in France, who have made original researches on the phys- 
iology, anatomy, and pathology of the female pelvic organs. The 
Germans and English, as we have already stated, have likewise distin- 
guished themselves by their surgical innovations in the same field : the 
French, after an intermission of many years following the era of 
Recamier, during which time they devoted themselves chiefly to the 
study of obstetrics, have recently shown an active interest in surgical 
gynecology, and some of their younger men are rapidly coming to 
the front. 

In the United States the practical tendency peculiar to the American 
people has shown itself more in the invention and popularization of 
technical and operative methods for the relief of suffering woman than 
by deep scientific researches into the structure and diseases of her 
pelvic organs. It is to this tendency that the world owes the idea ami 
the performance of the first ovariotomy by Ephraim McDowell of 



32 HISTORICAL SKETCH OF GYNECOLOGY. 

Kentucky in 1809, a now universally conceded fact. When Sims 
electrified the profession by his startling methods and operations, the 
old precepts of Meigs, Hodge, and Dewees were rapidly superseded, to 
a great extent at least, by the new surgical ideas and practice ; and 
since that time in no land has more been done for surgical gynecology, 
and nowhere have the teachings of foreign gynecologists been more 
eagerly followed, than in this country. In making this statement we 
must not forget that it was an American, Hugh L. Hodge of Phila- 
delphia, who first invented the ideal pessary for the support of the 
displaced uterus, which has served as the model for very nearly all 
subsequent pessaries which have stood the test of experience. Among 
other important discoveries emanating from this country, besides ova- 
riotomy, may be mentioned the introduction of ether as an anaesthetic 
in surgical operations, the revival of the method by which vesico- 
vaginal fistulae can be cured, the introduction into general practice of 
the examination of the pelvic organs by means of the Sims speculum, 
the removal of the normal ovaries for reflex nervous and mental dis- 
turbances, and the recognition of the importance of laceration of the 
cervix uteri as a factor in the production of uterine disease and its 
operative cure. 

We have already referred to the invention of Sims' s speculum and 
his method of examining the pelvic organs as inaugurating a new era 
in diagnosis and treatment. It may truly be said that from that period 
the practice of gynecology assumed an entirely new aspect, and possi- 
bilities were opened which before that time had no existence even in 
thought. With the old specula the vaginal walls were merely sepa- 
rated mechanically, and a limited view of them and the cervix was 
obtained. Manipulations and operations on the vagina and uterus were 
restricted so as to be almost valueless ; but through the Sims speculum, 
acting as it does partly by gravitation and atmospheric distension of the 
vaginal walls, that canal and the cervix uteri are exposed so as to be 
perfectly accessible both to the eye and to many very important surgical 
manipulations which without it would be entirely impracticable. Even 
as recently as the last edition of this book, eleven years ago, it was 
thought necessary to explain the preference of the author for Sims's 
speculum, and to enter a plea for its universal adoption. Now, in this 
country, at least, no such explanation and no such plea are needed. The 
Sims speculum is now used by every physician who makes a pretence 
of examining and treating utero-pelvic diseases after the most approved 
fashion. Its use is taught in all our colleges and hospitals ; all modern 
textbooks describe it ; and there is no longer any question as to its pre- 
eminence over all other specula. It is true that the necessity of having 
a nurse or assistant to hold it still renders it less popular with the gen- 
eral practitioner than tubular or valvular specula, but as all specialists 
in modern gynecology have found it indispensable to a proper exami- 
nation to see their patients at their offices, and to have in attendance 
a trained nurse who assists them during the examination, this objection 
naturally is done away with. The additional fact that it requires 
some experience to use Sims's speculum properly and painlessly will 
probably interfere with its ever becoming the favorite instrument of 



HISTORICAL SKETCH OF GYNECOLOGY. 33 

the general practitioner, but it is none the less true that it surpasses 
all other instruments of the kind. 

For the purpose of familiarizing the profession with the diagnosis and 
treatment of disease schools have recently been started in different parts 
of this country where purely clinical instruction is given in the affections 
of the female sexual organs as well as in other practical branches of 
medicine. This new departure may be justly regarded as an important 
step in medical instruction. Medical students during the time of their 
college course have neither leisure nor opportunity, nor, indeed, suf- 
ficient knowledge, to learn and appreciate the details necessary to the 
practice of a specialty ; later on, as practitioners, they know and feel 
their deficiencies, and find in these post-graduate schools the facilities 
which they necessarily missed before graduation. 

Scarcely a word need be said as to the extension of the practice 
of medicine to members of the female sex. Their ability and zeal are 
undoubted, and the fact that they have now achieved for themselves a 
position in medicine, and that many lady practitioners throughout the 
world are meeting with well-merited success, shows that they supply a 
want which has no doubt been long felt by many women who were 
averse to exposing themselves to a male physician. 

Among the greatest improvements in the surgical treatment of female 
diseases, may be justly classed the introduction into practice, chiefly as 
the result of the teachings of general surgery, of perfect, scrupulous 
cleanliness in all the dealings of the surgeon with his patients ; and this 
sine qua non can be obtained either by the use of chemical so-called 
germicidal solutions or by employing an abundance of soap and boiled 
water for the cleansing of hands, instruments, and living tissues which 
are liable to be infected. By the careful use of these precautions sur- 
gical operations, even of the greatest magnitude, in and outside of the 
peritoneal cavity, are now performed with perfect safety, with the almost 
absolute exclusion of the former danger of septic infection. 

We are so often consulted by recent graduates as to the works 
which they should make the basis of a library upon gynecology that 
we feel that we may render a service by the following list. The fol- 
lowing older authors may be of interest to the student of historical 
gynecology : Nonat, Aran, Becquerel, Blatin et Nivet, West, Tilt, 
Bennet, Simpson, Churchill, Sims, Baker Brown, Scanzoni, Meigs, 
Bedford, Colombat, Ashwell, McClintock, Hodge, Klob, Spencer 
Wells, Kiwisch, Wright, Duncan, Athill, Gallard, Atlee, Leblond. 

Of the modern textbooks we would recommend: Barnes, Byford, 
Skene, Hart and Barbour, Tait, Emmet, Hegar and Kaltenbach (Die 
Operative Gynakologie), Schroeder, Greig Smith (Abdominal Sur- 
gery), Munde (Minor Sury., Gynecology), Pozzi, Martin, Winckel, 
Fritsch, Graily Hewitt. 

The following journals are now devoted to this subject. 

American Journal of Obstetrics and Diseases of Women and Chil- 
dren ; Annals of Gynecology and Pad iatries ; British Gynaecological 
Journal; Centralblatt filr Gynakologie ; Zeitschrift fllr Greburtshiilfe 
und Gynakologie ; Arcliiv fur Gynakologie ; Annates de G yneeologie ; 
Archives de Tocologie. 



34 ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 



CHAPTER II. 
THE ETIOLOGY OF THE DISEASES PECULIAR TO WOMEN. 

In investigating the causes of the diseases peculiar to women we 
shall especially refer to those which are active in this country. In 
doing this we desire to avoid all comparison between the frequencv of 
such affections here and abroad, for in the absence of statistical evi- 
dence such an attempt would necessarily prove futile. Our chief reason 
for giving ourselves the limits herein prescribed is our desire to base 
the views advanced in this chapter entirely upon personal observa- 
tion — to offer to the reader not the conventional doctrines prevalent 
upon the subject of which it treats, but those views which have 
impressed themselves upon our own minds as valid and. valuable. With 
this object in view it is manifestly easier to write of habits and 
influences which come under one's daily observation and connect 
themselves with the experience of his daily life. 

We shall divide the causes to which we shall draw attention into pre- 
disposing and exciting, premising their enumeration by the announce- 
ment that we do not propose to mention all of the former which are 
active, but to limit ourselves to those which are most prominent and 
which are to a great degree avoidable. Others — such, for example, 
as inherited constitutional vices — will be spoken of in connection 
with special diseases as they come under notice. Considering very 
fully the predisposing causes, we shall give merely an enumeration of 
the chief exciting ones, leaving the fuller consideration of the latter 
also for chapters devoted to special affections. 

If we compare the present state of women in refined society over 
the world with that of the working peasants of the same latitudes, or 
with the North American squaws or the powerful negresses of the 
Southern States, we can with difficulty believe that they all sprung from 
the same parent stem and originally possessed the same physical capa- 
cities. Observation proves that women who are not exposed to depre- 
ciating influences can compete in strength and endurance with the 
men of their races, and in savage countries they are sometimes regard- 
ed as superior to them. In the lower orders of animals this equality is 
still more marked. The mare endures as much as the horse, and some 
of our most celebrated racers have represented the female sex. The 
lioness is fully as dangerous to the hunter as her more majestic consort, 
and the bitch proves as untiring in the chase as the most muscular 
dog in the pack. 

From all these facts we may logically argue that the human female, 
if properly developed and placed beyond causes which militate against 
her physical well-being, would be in no great degree the inferior of the 
male. This position we now assume, and maintain that the customs of 
civilized life have depreciated her powers of endurance and capacity 



ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 35 

for resisting disease. Our efforts will be directed to an endeavor to 
point out what these habits and influences are. We do not, of course, 
advance the statement that uterine diseases are unknown among unciv- 
ilized women, for we have too often seen prolapsus, retroversion, gran- 
ular degeneration, and kindred disorders among the former slaves of 
this country to do so. These affections were, however, rare among 
them, and not exceedingly common, as they are amongst our white 
women ; and even when they existed they did not so profoundly affect 
the constitutions of those suffering from them. As we shall hereafter 
point out, injuries inflicted by parturition play a most important role 
in the causation of these disorders. To such injuries as laceration of 
the perineum and cervix, disorders of involution, etc., the savage 
woman is unquestionably liable, and their occurrence would entail 
upon her the same evils which would result from them in the civilized. 
Yet how much less liable to their occurrence is the strong, well-devel- 
oped, muscular frame of the former than the delicate, sensitive organi- 
zation of the latter ! And even if exposed to the baneful influence of 
these accidents, how much more able is she to resist their depreciating 
influences ! There are in this city to-day thousands of poor women 
who go through the labors of their lives of drudgery with the 
uterus, vagina, and portions of the bladder and rectum in the condi- 
tion of complete prolapse, the first two organs entirely, and the last 
two in great degree, outside of their bodies. How differently would 
the refined woman of a higher sphere be affected by a similar con- 
dition, and how utterly wretched would her life ordinarily be ren- 
dered ! 

In a woman of robust frame, healthy nervous system, and perfect 
blood-state, who lives a rational and carefully regulated life, an accident 
occurring at parturition, during menstruation, or at any time discon- 
nected with these trying periods may produce serious disease. But in 
such a woman accidents are much less likely to occur, and even if they 
did so would produce much less serious consequences, than in one in 
whom the predisposing causes of disease of the genital system had for 
a lifetime, and even longer — for hereditary influences are powerful for 
evil in this connection — prepared the way for the easy establishment of 
pathological conditions. 

Those influences which, growing out of the physically depreciating 
habits of civilized life, tend most decidedly to develop a predisposition 
to diseases of the female genitalia may thus be enumerated : 

Neglect of outdoor exercise and physical development ; 

Overwork of brain, and excessive development of the nervous system ; 

Improprieties of dress ; 

Imprudence during menstruation ; 

Imprudence after parturition ; 

Non-recognition or neglect, on the part of the obstetrician, of inju- 
ries due to parturition ; 

Prevention of conception and induction of abortion ; 

Marriage with existing disease of genitalia ; 

Insufficient food ; 

Habitual constipation. 



36 ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 

Neglect of Exercise and Physical Development. — There can be no 
doubt of the fact that, as a general rule, in the higher walks of life 
throughout the civilized world, the female, from infancy to old age, 
takes much less exercise than the male, and in the United States, owing 
to peculiarities of climate, this disproportion is probably more marked 
than in the countries of Europe. It is true that the last twenty years 
have seen a most gratifying improvement in this respect, and that the 
practice of outdoor amusements, such as rowing, bowling, archery, 
tennis, walking, horseback exercise, etc., has become much more 
general. 

This, however, is greatly confined to the inhabitants of cities and to 
very young women, and even among these it must become much more 
general than it is to-day for it to produce the results which may in time 
be expected from it. The female by nature is, as a rule, much more 
inclined to a sedentary life than the male, and as her occupations keep 
her indoors, she is apt, whether living in city or country, to lose all taste 
for outdoor amusements, and to confine herself to the close, heated air 
of inhabited apartments. Among our farming population, where all 
the outdoor work is done by the males, the women commonly take less 
exercise in the open air than do those in our cities, and much of their 
time is spent in rooms heated by stoves which cook the air and render 
it dry and unwholesome. 

In spite of the improvement we have mentioned, in our cities will 
to-day be found hundreds of ladies who do not w T alk a mile a day for 
weeks together, and many more who have never engaged in any exer- 
cise which called forth the action of other muscles than those employed 
in the quietest locomotion. 

But nowhere is the neglect of early physical development more 
marked than in our boarding-schools and female seminaries, where 
every hour of the day from six in the morning to nine at night is 
allotted by rule to some special task. Instead of the girls being encour- 
aged to engage in outdoor pursuits calculated to create muscular power, 
they are reared in the belief that such pastimes are hoydenish, unbe- 
coming, and fit only for rough boys. Their hours of leisure are occu- 
pied by reading, music, drawing, or some similar light task, and an 
hour's walk every day is regarded as a degree of exercise quite suf- 
ficient for the requirements of health. By this plan the mind is con- 
stantly kept in the thraldom of control and chafes under the depressing 
influence of a never-ending surveillance. A set of romping school- 
girls could as profitably laugh by rule as really enjoy and improve by 
exercise under the eye of an instructress or professor of calisthenics. 
It is not the mere bodily exertion which is of benefit, but the total 
mental relaxation, the exhilaration, and the abandon which accompany 
it. The prisoner working for eight hours on the treadmill does not 
profit by it as the free and happy equestrian or oarsman does by one- 
eighth the time of exercise. 

It is but fair to say that during the last few years a very marked 
improvement has taken place in this respect, and that now the majority 
of the advanced schools for young girls devote one or more hours 
every day to the systematic instruction of the pupils in calisthenics 



ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 37 

and gymnastic exercises. Whether all the sanitary and medical pre- 
cautions are observed during these exercises which are particularly 
applicable to young girls is to us still a matter of some doubt. Per- 
sonally, we know that, no matter whether menstruation be present or 
not, in some schools the regular routine of physical and mental exercise 
is not interrupted. Obviously, at the very time when the organs are 
developing their normal physiological functions such a course can but 
produce evil results. 

One of the most important results of exercise is the increase of 
the peripheral circulation. This increases cutaneous exhalation and 
tends to equalize the circulation. The woman who neglects it is 
peculiarly prone to excessive uterine and ovarian congestion at men- 
strual epochs, and to sluggish circulation in these parts at all times. 
It is this fact which explaims the excellent results attainable in cases 
of uterine and ovarian disease from the use of passive motion by the 
Swedish movement cure, the Turkish bath, surf-bathing, and other 
methods which create turgescence of the cutaneous capillaries and 
exalt metamorphosis of tissue in the periphery of the body. One of 
the most valuable and beneficent means of treating these diseases that 
we know of is the use night and morning of a warm sponge-bath of 
water strongly impregnated with salt, followed by thorough friction with 
a rough towel and calisthenic exercises for five or ten minutes. 

Excessive Development of the Nervous System. — The necessity for 
a due proportion existing between the development and strength of the 
nervous and muscular systems has always been recognized, and has 
given rise to the trite formula, "mens sana in corpore sano," as essen- 
tial to health. Unfortunately, the restless, energetic, and ambitious 
spirit which actuates the people of the United States has prompted a 
plan of education which by its severity creates a vast disproportion 
between these two systems, and its effects are more especially exerted 
upon the female sex, in which the tendency to such loss of balance is 
much more marked than in the male. Girls of tender age are required 
to apply their minds too constantly, to master studies which are too 
difficult, and to tax their intellects by efforts of thought and memory 
which are too prolonged and laborious. The results are — rapid develop- 
ment of brain and nervous system, precocious talent, refined and 
cultivated taste, and a fascinating vivacity on the one hand ; a morbid 
impressibility, great feebleness of muscular system, and marked tendency 
to disease in the generative organs on the other. 

That this statement of the advantages which are gained and the 
price which is paid for them is perfectly true no American practitioner 
will deny. But the mere existence of the fact is not the most melan- 
choly feature of the case; it is far more painful to see mothers listening 
to it, admitting its truth, and yet calmly and dispassionately choosing 
to make the trial, as we see them doing constantly. 

When the day arrives in which our young growing girls are educated 
physically with the assiduity and system now bestowed upon their men- 
tal culture, when mothers desire to see their daughters grow up strong, 
well-developed, muscular women, and not merely highly educated and 



38 ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 

accomplished valetudinarians, one of the most prolific of the predis- 
posing causes of disease of the genital organs will have disappeared. 
No amount of mental labor, no degree of mental culture, will fit a 
woman for the physical duties of wife and mother, or render her capable 
of bearing children competent to resist the inroads of disease. 

In a woman developed by this pernicious system the physiological 
congestion of the pelvic organs attending ovulation produces pain 
which is known as "neuralgic dysmenorrhea ;" ovulation becomes 
irregular and abnormal, favoring the development of subacute oophoritis ; 
the normal hypertrophy of the uterus consequent upon utero-gestation 
slowly and imperfectly passes off, subinvolution often remaining ; while 
the enfeebled muscular supports of the heavy organ allow it to lapse 
from its position and assume that of flexion or version. 

Improprieties of Dress. — The dress adopted by the women of our 
times may be very graceful and becoming, it may possess the great 
advantages of developing the beauties of the figure and concealing its 
defects, but it certainly is conducive to the development of uterine 
diseases, and proves not merely a predisposing, but an exciting cause, 
of them. For the proper performance of the function of respiration 
an entire freedom of action should be given to the chest, and more 
especially is this needed at the base of the thorax, opposite the attach- 
ment of the important respiratory muscle, the diaphragm. The habit of 
contracting the body at the waist by tight clothing confines this part as 
if by splints ; indeed, it accomplishes just what the surgeon does who 
bandages the chest for a fractured rib, with the intent of limiting 
thoracic and substituting abdominal respiration. 

As the diaphragm, thus fettered, contracts, all lateral expansion 
being prevented, it presses the intestines upon the movable uterus, and 
forces this organ down upon the floor of the pelvis or lays it across it. In 
addition to the force thus exerted, a number of pounds, say from five 
to ten, are bound around the contracted waist and held up by the hips 
and the abdominal walls, Avhich are rendered protuberant by the com- 
pression alluded to. The uterus is exposed to this downward pressure 
for fourteen hours out of every twenty-four ; at stated intervals being 
still further pressed upon by a distended stomach. 

In estimating the effects of direct pressure upon the position of the 
uterus its extreme mobility must be constantly borne in mind. No 
more striking evidence of this can be cited than the fact that in exam- 
ining it by Sims's speculum, if the clothing be not loosened around the 
waist the cervix is thrown so far back into the hollow of the sacrum as 
to make its engagement in the field of the instrument often very 
difficult, and that attention to this point in the arrangement of the 
patient will at once remove the difficulty. While the uterus is exposed 
by the speculum it will be found to ascend with every expiratory effort 
and descend with every inspiration ; and so distinct and constant are 
the rapid alterations of position thus induced that in operations in the 
vaginal canal the surgeon can tell with great certainty how respiration 
is being affected by the anaesthetic employed. An organ so easily and 
decidedly influenced as to position by such slight causes must neces- 



ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 39 

sarily be affected by a constriction which, in autopsy, will sometimes be 
found to have left the impress of the ribs upon the liver, producing 
depressions corresponding to them. 

Corseting, lacing, and the wearing of tight and heavy clothing also 
produce a deleterious effect in quite another way. Pressure against the 
abdominal and thoracic muscles and over the diaphragm produces in 
them a partial paresis. This impairs abdominal as well as thoracic res- 
piration, to a great extent counteracts the important retentive power 
of the abdomen over the pelvic viscera, and allows the influence of 
gravitation, which before was by that means antagonized, to cause dis- 
placement. This result of a pernicious habit cannot be too thoroughly 
appreciated or too much insisted upon. So prominent is it in etiology 
that Ave might well have considered it under the head of exciting causes. 
By the direct influences of pressure just considered, and the paresis of 
thoracic, abdominal, and diaphragmatic muscular fibres now alluded 
to, the abdominal viscera press upon the growing uterus of the young 
girl, and, the fundus being bent toward the cervix, one uterine wall 
develops much more rapidly than the other, and at puberty the men- 
strual effort finds itself interfered with by closure of the cervical canal, 
and an origin for uterine disease is created thereby. 

To a Avoman who has systematically displaced her uterus by years 
of imprudence the act of sexual intercourse, which in one whose organs 
maintain a normal position is a physiological process devoid of patho- 
logical results, becomes an absolute and positive source of disease. The 
axis of the uterus is not identical with that of the vagina. While the 
latter has an axis coincident with that of the inferior strait, the former 
has one similar to that of the superior. This arrangement provides for 
the passage of the male organ below the cervix into the posterior cul- 
de-sac, the cervix thus escaping injury. But let the uterus be forced 
down, as it is by the prevailing styles of fashionable dress, even to the 
distance of one inch, and the natural relation of the parts is altered. 
The cervix is directly injured, and thus a physiological process is in- 
sensibly merged into one productive of pathological results. How often 
do we see uterine disease occur just after matrimony, even where no 
excesses have been committed ! It is not an excessive indulgence in 
coition which so often produces this result, but the indulgence to any 
degree on the part of a woman who has distorted the natural relations 
of the genital organs. 

But this is by no means the only method by which displacement of 
the uterus may induce disease of its structures. It disorders the circu- 
lation in the displaced organ, and produces passive congestion and its 
resulting hypertrophy, prevents the free escape of menstrual blood by 
pressing the os against the vagina, creates flexion, causes friction of the 
cervix against the floor of the pelvis, and stretches the uterine liga- 
ments and destroys their power and efficiency. 

These facts should be carefully borne in mind by the physician who 
attempts to relieve uterine displacements by the use of pessaries. If he 
merely replaces the displaced organ and relies for its support upon a 
pessary, he will often fail in accomplishing the desired result. lie is 
striving at great disadvantage with a short lever power against the 



40 ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 

weight, not of the uterus alone, but of the superimposed viscera pressed 
downward by several pounds of clothing, which add their weight at the 
same time that they constrict the waist and substitute abdominal for 
thoracic respiration. Thus employed, the pessary will often give great 
pain, and so injure the parts upon which it rests as to necessitate 
removal, and the practitioner will find himself cut off from one of his 
most valuable resources. Should he, on the other hand, before 
employing a pessary, remove all constriction and weight from the 
abdominal walls, employ a well-fitting abdominal supporter over the 
hypogastrium, so as to aid the exhausted abdominal muscles in their 
work, keep the displaced and congested uterus out of the cavity of the 
pelvis by a tampon of medicated cotton, or bring gravitation to his 
assistance by the position of the patient, he will ordinarily at the end 
of a week be able to employ with great advantage the same pessary 
which at first seemed to accomplish evil and not good. 

Imprudence during Menstruation is a prolific source of disease. 
Some women, through ignorance, many through recklessness, and a 
few from necessity, go out lightly clad in the most inclement weather 
during this period, and many suffer in consequence from violent con- 
gestive dysmenorrhea, and often from endometritis. Every practi- 
tioner will meet with a certain number of cases of uterine disease which 
have this origin, and run on for years, ending, perhaps, in parenchy- 
matous disease which may prove incurable. 

During a period in which the ovaries and uterus are intensely 
engorged, in which the surface of the ovary is broken through by the 
escaping ovule, and the nervous system is in an unusual state of 
excitability, ordinary prudence would suggest that the body should be 
well covered, that the congested organs should be left at rest, and that 
exposure to cold and moisture should be sedulously avoided. We need 
scarcely say that infractions of this rule are of every-day occurrence, 
and that cases come continually to our knowledge where women, even 
of the highest intelligence, expose themselves to the dangers of cold 
and violent exercise by skating, dancing, and long walks during the 
menstrual period. 

The immediate result of exposure during menstruation is most com- 
monly inflammation of the mucous membrane of the uterus. Such an 
inflammation, once excited, will often go on for years, and in time end 
in parenchymatous disease, entailing in its progress dysmenorrhoea, 
sterility, pelvic pain, and gastric disorders which impair indigestion 
and nutrition. Many cases, too, of pelvic peritonitis, cellulitis, and 
hematocele develop at this trying period of congestion and nervous 
exaltation. 

Imprudence after Parturition. — No sooner does fixation of the 
impregnated ovum upon the uterine surface occur than a surprising 
stimulation is exerted upon the fibre-cells forming part of the uterine 
parenchyma, which grow with rapidity, enlarging the organ pari passu 
with the requirements of its increasing contents. After the expulsion 
of the embryo, either at full time or at any period of pregnancy, the 



ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 41 

fibres thus developed undergo a fatty degeneration and absorption, 
which has received the name of involution. This process occurs rap- 
idly after abortion, but after labor at term it requires six weeks for its 
full accomplishment. In order that it may proceed with normal rapid- 
ity and certainty perfect rest is essential, and the woman who rises 
too soon, and resumes her usual occupations while the lochial discharge 
is still existing, risks the results of interference with it. Besides this, 
the uterus is much heavier than usual, and the additional danger of 
the induction of displacement is incurred by too early exertion. Lastly, 
the mucous membrane lining the cavity of the uterus is for some time 
after parturition in an abnormal state, and is peculiarly liable to dis- 
ease from exposure to cold and moisture. A very valid objection may 
be made to this view that in the lower walks of life women rise after 
labor and attend to their duties with impunity on about the ninth day, 
and yet enjoy a marked immunity from uterine affections. This is 
true ; but let it be remembered that they are unaffected by the influ- 
ences to which we have alluded as calculated to enfeeble and deteriorate 
their generative systems. 

Another influence connected with parturition, which develops itself 
much more decidedly among the higher than the lower classes, is the 
pernicious habit of tight bandaging. For three or four weeks after 
delivery the nurse commonly applies two folded towels over the enlarged 
uterus, and by powerful compression by a bandage forces the organ 
backward into the hollow of the sacrum. This is supposed to preserve 
the comeliness of the figure, and the reputation of many a nurse rests 
mainly upon the thoroughness with which she develops an influence 
that is fruitful of evil in displacing an enlarged uterus in a woman 
who for a fortnight at least lies chiefly upon her back. That a w t ell- 
fitting bandage, only tight enough to give support, applied after deliv- 
ery, proves a source of comfort to the woman, we are not disposed 
to deny. In this way we have always employed one. But we feel 
very sure that a great deal of superstition attaches in the lying-in 
room to this appliance, both as a means of preventing deterioration of 
the figure and post-partum hemorrhage. Uterine contraction should be 
secured by vital, not mechanical, means, and no amount of compression 
by a bandage will cause the over-distended abdominal muscles, skin, 
fasciae, and areolar tissue to return to their original condition. Not 
only should tight bandaging be avoided after delivery, but the position 
should be systematically changed at intervals from the dorsal to the 
lateral decubitus. We are convinced that uterine displacement is one 
of the most fruitful causes of subinvolution. As, during the six weeks 
or two months succeeding delivery, the process of retrograde metamor- 
phosis, called involution, progresses, the uterus, under untoward influ- 
ences, many of which are developed by the routine management of the 
lying-in chamber, becomes displaced. This results in impeded venous 
return from its tissues; the process of involution is checked ; and months 
or years afterward the patient, being forced to apply to a physician, is 
informed that she has suffered and is suffering from metritis of a chronic 
character of which displacement is a complication or result. 

Every practitioner frequently hears that some lady has been injured 



42 ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 

for life " because she was not property bandaged at lier last confine- 
ment," and either doctor or nurse, possibly both, are severely censured 
for the culpable neglect. Too often such censure is listened to in silence, 
and the party supposing herself injured is allowed to hold the same opin- 
ion still. It is the duty of every physician to inform those coming under 
his influence as to the futility of trusting to the obstetric bandage, or, if 
he cannot conscientiously do so, to review his opinion upon the subject 
and see whether his own confidence is not misplaced. 

Non-recognition or Neglect of Injuries due to Parturition. — When 
it shall become the duty of the obstetrician, as it surely soon will do 
under the influence of advancing knowledge, before relinquishing the 
care of the recently-delivered woman to inform himself thoroughly as 
to the existence of laceration of the cervix or perineum ; when the false 
and vicious doctrine of undervaluing and ignoring these grave accidents 
is silenced for ever ; and when a neglect of their early repair by surgi- 
cal resort shall be regarded as a flagrant obstetrical dereliction, — then 
the number of women affected by pelvic disorders will become suddenly 
and wonderfully diminished. Since the last edition of this book was 
written a great and very salutary change has taken place in that part 
of the medical profession which practices obstetrics, chiefly in conse- 
quence of the dissemination of the doctrines of antisepsis. Nowadays, 
no physician who lays claim to an honest and conscientious performance 
of his duties will attend an obstetric case without a scrupulous attention 
to all the minute details as regards cleanliness of person, instruments, 
and clothes which his patient's safety from septic infection demands. 
The old idea that the functions of the obstetrician consisted merely in 
watching by the woman's bedside until the child was ready to be born, 
then assisting in its safe delivery, and, after having performed the duties, 
now relegated to the trained nurse, of making mother and child com- 
fortable, taking his departure with a few well-turned compliments, is 
now happily — at least among progressive practitioners — a thing of the 
past. An obstetrician at the present time should be chosen not so much 
for his courtliness of manner and kindness of disposition, as for his skill 
in diagnosis and operating and his scrupulous attention to the improved 
practices of modern times. It is to these, particularly to the observance 
of antiseptic rules, that the present exceedingly low mortality from 
obstetric causes is due. Unfortunately, in spite of all our teachings, 
there are still practitioners who, day after day, year after year, send forth 
women with lacerated cervices and ununited perinea to furnish to the 
gynecologist in the future cases of uterine engorgement, leucorrhcea, 
prolapsus and other displacements, cystitis, and a long list of patho- 
logical conditions which will cling to them for life, sapping their use- 
fulness and destroying the happiness of their households. 

Prevention of Conception and Induction of Abortion. — Means 
established for the accomplishment of the first of these ends are often 
productive of uterine disorder. This will not be wondered at when the 
harshness of some of them is borne in mind. The workings of nature 
in this, as in all other physiological processes, are too perfect, too accu- 



ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 48 

rately and delicately adjusted, not to be interfered with materially by 
the clumsy and inappropriate, measures adopted to frustrate them. 
The practice is becoming exceedingly common, as every physician is 
aware — so common, indeed, that in the older portions of this country, 
unfortunately, it must be said, in the more civilized and educated, it is 
by no means usual to meet with large families of children. 

The fact is not an agreeable one to deal with, and the facts which 
we are citing may prove unacceptable to many of our countrymen, but 
it is one which is rapidly assuming proportions w 7 hich must influence 
the future population of our country. It is useless to ignore it. If 
an evil is to be eradicated, the first step toward such a consummation 
is its recognition, and what class of men can more immediately and 
more effectually grapple with this one than physicians ? 

With these statements we leave this unattractive subject to deal 
with another, which from its importance cannot conscientiously be 
passed over in silence. Statistics showing the frequency of criminal 
abortion never have been, and never will be written, for the crime 
creeps stealthily beneath the scrutiny of society. That this criminal 
practice constitutes a prolific source of uterine disease no one engaged 
in gynecology can for a moment doubt. So impressed with this fact 
are the physicians of the United States that some years ago, at its 
meeting in New York, the American Medical Association offered a 
prize for a " short and comprehensive tract for circulation among 
females for the purpose of enlightening them upon the criminality and 
physical evils of forced abortions." Unfortunately, in spite of the 
many warnings and exhortations both from the medical and clerical 
profession, this crying evil is still by far too prevalent among even the 
higher ranks of our society. And the scoundrel who grows rich by 
pandering to the evil instincts of women who for the sake of conve- 
nience, economy, or secrecy apply to be rid of their burden, goes on 
unpunished in the face of our criminal laws and our emphatic protests. 
Only the most strenuous enforcement of the existing or the enactment 
of new, still more stringent laws, together with the inculcation of a 
more healthy sentiment by the medical profession and the clergy, would 
gradually diminish the evil. 

Marriage with Existing Uterine Disease. — It is a common practice 
with physicians to recommend marriage as a cure for uterine disease. 
There are a sufficient number of abnormal conditions which childbear- 
ing cures to make the practice appear legitimate, but a vast deal of 
harm frequently results from it. A constricted cervix which causes 
dysmenorrhoea, a pure endometritis of neck or body, or an inactive 
state of the ovaries which results in amenorrhea, may be relieved by 
the parturient act; but displacement, peri-uterine cellulitis, or pelvic 
peritonitis will very often produce evil results after labor, and very gen- 
erally return with renewed violence as soon. as involution has been 
accomplished. The advice is too often given empirically, and. like all 
such counsel, is hazardous in its results. Our experience leads us to 
fear a return of such conditions after childbearing, even in a patient 
whom w r e considered cured at the time o\' marriage. The obvious rem- 



44 ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 

edy in such cases is to advise a local examination if the symptoms 
seem to warrant it, and the adoption of the proper treatment for the 
cure of the case. It is better that an unmarried woman should be 
subjected to the trial and discomfort of such examination and treat- 
ment than that her married life should be rendered wretched by some 
previously unrecognized pelvic disease. 

Insufficient Food. — Many diseases of the uterus are established, 
and a still larger number perpetuated, by impoverished blood and the 
disordered nerve -state dependent upon spanseinia. So well known is 
this fact that a generous diet commonly constitutes an important ele- 
ment of treatment, and its result in improved hematosis is hailed as 
the harbinger of approaching improvement. The tone of the uterus — 
that is, its muscular strength and power of resistance — is decidedly 
affected by want of sufficient nutrient material, and flexions are a frequent 
consequence, as Dr. Graily Hewitt has ably pointed out ; engorgement 
of the mucous membranes of the uterus, Fallopian tubes, and vagina is 
favored by the same influence ; and it is beyond doubt that a feeble, 
atonic state of the uterine ligaments is engendered and kept up by it. 
To no nation in the world is a full supply of the most nutritious food 
so attainable as to the inhabitants of the United States. And yet it 
is no exaggeration to maintain that the American woman, except in 
our cities, is at least half starved. She suffers not from an enforced 
but a voluntary starvation, which, however, none the less impoverishes 
her blood and impairs her nerve-power. Let any one travel through 
our farming regions and examine closely the women with whom he 
meets, and he must admit that the robust, buxom, florid lass and 
matron is the exception ; the pale, lank, and emaciated the rule. 

These women are not overworked, for this country knows no hard- 
worked peasantry, They are under-fed, however, from their cradles to 
their graves. It must be remembered that it is not merely material 
introduced into the stomach which nourishes the body, but the intro- 
duction of material capable of making blood of good quality which 
does so. The eating of salt fish and meats in place of fresh, the drink- 
ing of large amounts of tea in place of milk and malt liquors, and the 
consumption of incalculable amounts of the noxious and inevitable pie 
of the Eastern States in place of bread and nutritious puddings, will 
never answer the requirements of nutrition until the laws which govern 
that process are altered. 

The American travelling in Great Britain is always struck by the 
large amounts of nutritious food, of malt liquors, and of the products 
of the dairy which are consumed, as well as by the amount of time 
given to their consumption, and very often he plumes himself upon the 
more elegant habits of his own country. In vain do we look among 
our women for justification for such self-congratulation, and most earn- 
estly would we urge an imitation of customs which would greatly 
improve our own condition. 

Habitual Constipation. — A large proportion of women who, after 
puberty, marriage, and maternity, suffer from uterine disease, do so in 



ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 45 

consequence of deformities of the uterus developing between the period 
of infancy and that of womanhood. One of the most frequent and 
obstinate of these is cervical anteflexion. In this state the body of the 
uterus does not alter its position, but the cervix is bent sharply for- 
ward, creating a stricture at or near the os internum uteri, and causing 
obstruction to the escape of fluids from the uterus and interference with 
its venous circulation. The habit of allowing large, hard masses of 
fecal matter to remain not only for days, but for a week at a time, in 
the rectum, as many women do, contributes largely to the occurrence of 
this deformity in the soft, pliable growing uterus of girlhood. 

Alone, it is sufficient to bend the uterus and give it the shape of a 
gourd, but combined with pressure from above by tight, heavy clothing 
constricting the waist, it is not astonishing that it very often produces 
this common disorder of the shape of the organ. Once produced, it is 
a condition which pretty surely results in endometritis, dysmenorrhcea, 
and sterility, and it is one rarely remediable except by resort to surgery. 

Let us present a picture, simple and unexaggerated in its details, 
of millions of our women who are exposed to the baneful influences 
which we have endeavored to portray : The woman is flat-chested, 
slightly round-shouldered, and thin almost to emaciation. Her hands 
and feet are cold, and her facies is not one suggestive of hilarity or 
buoyancy of spirit. Auscultate the thoracic organs, and a slight basic 
murmur will be heard over the heart, and the respiration will be found 
feeble and inefficient. Tell the patient to inflate the lungs fully, and 
the effort is so poor an one that it is seen at once that a full inspiration 
is a rare matter with her. She craves such stimulants as tea, and desires 
as food articles which are sweet. The bowels are almost invariably 
constipated, and an examination of the skin shows that it is inactive 
and that its vessels are not filled with red blood, but shrunken and 
atonic. 

She is nevertheless in excellent health, does a large amount of 
work in her house, and perhaps for a long lifetime fulfils all the require- 
ments of her existence. So she willingly allows her daughters to follow 
in her footsteps. And yet how thoroughly is this woman fulfilling 
every indication which is necessary to cause her to fall an easy prey 
to disease of the sexual organs as to that of any other organ in the 
body ! 

The interdependence of the various physiological processes one upon 
the other is very striking. Primary nutrition keeps the blood in 
healthy state, respiration keeps it in active circulation, and action of 
the muscles stimulates and makes perfect the flow through the capillary 
vessels of the skin, liver, kidneys, and all the other organs of the body. 
Derangement in any one of these processes creates disorder in others. 
Impoverished blood entails imperfect circulation, deficient respiratory 
effort furthers this, and an inactive state of the muscles tends to pro- 
duction of local hyperemia by allowing blood-stasis in the deeper parts 
of the body. All this renders excretion inefficient, and the nerve- 
centres soon feel the benumbing influence of a slow toxaemia. It is 
evident that the influences which we have mentioned tend very decid- 
edly to disorder the system in this way. 



44 ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 

edy in such cases is to advise a local examination if the symptoms 
seem to warrant it, and the adoption of the proper treatment for the 
cure of the case. It is better that an unmarried woman should be 
subjected to the trial and discomfort of such examination and treat- 
ment than that her married life should be rendered wretched by some 
previously unrecognized pelvic disease. 

Insufficient Food. — Many diseases of the uterus are established, 
and a still larger number perpetuated, by impoverished blood and the 
disordered nerve -state dependent upon spanseruia. So well known is 
this fact that a generous diet commonly constitutes an important ele- 
ment of treatment, and its result in improved hematosis is hailed as 
the harbinger of approaching improvement. The tone of the uterus — 
that is, its muscular strength and power of resistance — is decidedly 
affected by want of sufficient nutrient material, and flexions are a frequent 
consequence, as Dr. Graily Hewitt has ably pointed out ; engorgement 
of the mucous membranes of the uterus, Fallopian tubes, and vagina is 
favored by the same influence ; and it is beyond doubt that a feeble, 
atonic state of the uterine ligaments is engendered and kept up by it. 
To no nation in the world is a full supply of the most nutritious food 
so attainable as to the inhabitants of the United States. And yet it 
is no exaggeration to maintain that the American woman, except in 
our cities, is at least half starved. She suffers not from an enforced 
but a voluntary starvation, which, however, none the less impoverishes 
her blood and impairs her nerve-power. Let any one travel through 
our farming regions and examine closely the women with whom he 
meets, and he must admit that the robust, buxom, florid lass and 
matron is the exception ; the pale, lank, and emaciated the rule. 

These women are not overworked, for this country knows no hard- 
worked peasantry, They are under-fed, however, from their cradles to 
their graves. It must be remembered that it is not merely material 
introduced into the stomach which nourishes the body, but the intro- 
duction of material capable of making blood of good quality which 
does so. The eating of salt fish and meats in place of fresh, the drink- 
ing of large amounts of tea in place of milk and malt liquors, and the 
consumption of incalculable amounts of the noxious and inevitable pie 
of the Eastern States in place of bread and nutritious puddings, will 
never answer the requirements of nutrition until the laws which govern 
that process are altered. 

The American travelling in Great Britain is always struck by the 
large amounts of nutritious food, of malt liquors, and of the products 
of the dairy which are consumed, as well as by the amount of time 
given to their consumption, and very often he plumes himself upon the 
more elegant habits of his own country. In vain do we look among 
our women for justification for such self-congratulation, and most earn- 
estly would we urge an imitation of customs which would greatly 
improve our own condition. 

Habitual Constipation. — A large proportion of women who, after 
puberty, marriage, and maternity, suffer from uterine disease, do so in 



ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 45 

consequence of deformities of the uterus developing between the period 
of infancy and that of womanhood. One of the most frequent and 
obstinate of these is cervical anteflexion. In this state the body of the 
uterus does not alter its position, but the cervix is bent sharply for- 
ward, creating a stricture at or near the os internum uteri, and causing 
obstruction to the escape of fluids from the uterus and interference with 
its venous circulation. The habit of allowing large, hard masses of 
fecal matter to remain not only for days, but for a week at a time, in 
the rectum, as many women do, contributes largely to the occurrence of 
this deformity in the soft, pliable growing uterus of girlhood. 

Alone, it is sufficient to bend the uterus and give it the shape of a 
gourd, but combined with pressure from above by tight, heavy clothing 
constricting the waist, it is not astonishing that it very often produces 
this common disorder of the shape of the organ. Once produced, it is 
a condition which pretty surely results in endometritis, dysmenorrhcea, 
and sterility, and it is one rarely remediable except by resort to surgery. 

Let us present a picture, simple and unexaggerated in its details, 
of millions of our women who are exposed to the baneful influences 
which we have endeavored to portray : The woman is flat-chested, 
slightly round-shouldered, and thin almost to emaciation. Her hands 
and feet are cold, and her facies is not one suggestive of hilarity or 
buoyancy of spirit. Auscultate the thoracic organs, and a slight basic 
murmur will be heard over the heart, and the respiration will be found 
feeble and inefficient. Tell the patient to inflate the lungs fully, and 
the effort is so poor an one that it is seen at once that a full inspiration 
is a rare matter with her. She craves such stimulants as tea, and desires 
as food articles which are sweet. The bowels are almost invariably 
constipated, and an examination of the skin shows that it is inactive 
and that its vessels are not filled with red blood, but shrunken and 
atonic. 

She is nevertheless in excellent health, does a large amount of 
work in her house, and perhaps for a long lifetime fulfils all the require- 
ments of her existence. So she willingly allows her daughters to follow 
in her footsteps. And yet how thoroughly is this woman fulfilling 
every indication which is necessary to cause her to fall an easy prey 
to disease of the sexual organs as to that of any other organ in the 
body! 

The interdependence of the various physiological processes one upon 
the other is very striking. Primary nutrition keeps the blood in 
healthy state, respiration keeps it in active circulation, and action of 
the muscles stimulates and makes perfect the flow through the capillary 
vessels of the skin, liver, kidneys, and all the other organs of the body. 
Derangement in any one of these processes creates disorder in others. 
Impoverished blood entails imperfect circulation, deficient respiratory 
effort furthers this, and an inactive state of the muscles tends to pro- 
duction of local hyperiemia by allowing blood-stasis in the deeper parts 
of the body. All this renders excretion inefficient, and the nerve- 
centres soon feel the benumbing influence of a slow toxaemia. It is 
evident that the influences which we have mentioned tend very decid- 
edly to disorder the system in this way. 



46 ETIOLOGY OF DISEASES PECULIAR TO WOMEN. 

This completes the list of those influences which, in our 
most markedly predispose to disease of the female genitalia in the 
United States. In reviewing them we trust that we have not spoken 
in a tone of exaggeration of an} T one of them. 

There are two points in this connection which we would earnestly insist 
upon, and concerning which we feel that the medical profession is greatly 
at fault. The first is the prevalent idea that there is in woman an 
inherent tendency to disease of the sexual organs, that she is born to 
these affections " as the sparks fly upward," and that an entire immunity 
from them is a lucky circumstance which is rather a cause for surprise. 
The second is the belief that, these disorders being contracted, not from 
avoidable but from inevitable causes, the woman herself is not respon- 
sible for them. Once falling a victim, she immediately puts herself 
under the care of a physician, and then very likely follows a lengthy 
and tedious course of local treatment. 

Surely one of the highest duties of the physician is to disseminate 
correct views upon these points, one of his greatest derelictions endors- 
ing them by tacit consent. 

We shall deal very cursorily with the exciting causes of these 
diseases, for the reason already given. We would not, indeed, have 
alluded to them here were it not that the opportunity for enumerating 
them in this connection appeared to be too important a one to be lost. 
The chief of these may thus be tabulated: 

1st. Injuries inflicted by parturition — e. g. laceration of cervix and 
perineum ; pudendal and subperitoneal hematocele ; and inversion of 
the uterus. 

2d. Derangements of involution — e. g. subinvolution of uterus, 
vagina, perineum, and uterine ligaments ; superinvolution of uterus ; 
fungoid degeneration of the endometrium ; retention of foetal enve- 
lopes ; displacements of the uterus. 

3d. Congenital and infantile anomalies in shape, proportions, and 
position of genitalia — e. g. flexion ; undeveloped state of cervix, of 
body of uterus, or of both ; contractions of cervical canal ; absence 
or imperfect development of ovaries ; and similar imperfections of the 
vagina. 

4th. Sudden violent and unaccustomed efforts, producing flexions, 
versions, and prolapse. 

5th. The development of neoplasms in connection with any of the 
genital organs — e. g. fibroids or cysts of the uterus, vagina, or ovaries ; 
adenoma, sarcoma, cancer, etc. 

6th. Deposits of lymph throughout the pelvis from general perito- 
nitis, causing displacements of uterus and ovaries ; ovarian engorgement 
and neuralgia ; congestion of all the pelvic organs. 

7th. Local treatment and examination by sounds, tents, etc., caus- 
ing peritonitis, septicaemia, and cellulitis. 

8th. Contamination by gonorrhoeal or syphilitic virus, causing endo- 
metritis, salpingitis, pelvic peritonitis, and development of syphilitic 
abrasions and neoplasms. 

9th. Means adopted for prevention of conception and production of 
criminal abortion, causing endometritis, pelvic peritonitis and cellu- 



UTERINE PATHOLOGY AND TREATMENT. 47 

litis, fungoid degeneration of endometrium, septicaemia, and retention 
of the foetal envelopes. 



CHAPTER III. 

GENERAL CONSIDERATIONS UPON UTERINE PATHOLOGY AND 

TREATMENT. 

Let us suppose that a woman, born of a mother who has transmitted 
to her a rather feeble constitution, lives such a life as to expose herself 
to enfeeblement of the nerve-power, impoverishment of the blood, and 
local disorders of the circulation from the predisposing causes men- 
tioned in the last chapter. These alone are sufficient to establish in 
her disease of the sexual organs ; or, if they do not do so, one of the 
exciting causes enumerated may supervene, and, falling upon well-pre- 
pared ground, the seeds of disease thus sown thrive luxuriantly. Let 
us consider the pathological steps by which the various pelvic diseases 
peculiar to her sex are developed. 

Up to a recent date the subject of uterine pathology — that is to say, 
of the chief factors to which utero-pelvic disease may be said to be 
due — was in a chaotic condition, the like of which existed in none of 
the other departments of medical science. Theory after theory of ute- 
rine pathology had been started, more or less successfully proclaimed 
and defended by its originator and his disciples, only to drop back 
eventually to the obscurity where it properly belonged. Thus, one 
gentleman believed that all the diseases peculiar to females depended 
upon engorgement and inflammation of their sexual organs ; another, 
that the nerves of those organs were solely at fault ; a third attributed 
everything to displacements of the uterus ; while a fourth considered 
the parturient process to be entirely chargeable with all subsequent 
disturbances. Finally, chiefly during the last twenty-five years, fol- 
lowing the lead of our own Sims, the mechanical and surgical school 
have endeavored to prove that in congenital and acquired distortions, 
and in diseased conditions remediable only by mechanical appliances and 
the knife, lay the great and only truth. It seems almost unnecessary to 
say, in the light of our present knowledge and experience, that none 
of these different theories or practices are solely and entirely in the 
right. In our opinion, probably by far the largest number of diseased 
conditions of the female pelvic organs are due to the results of parturi- 
tion. Following these may come the injuries produced by imprudence 
during menstruation, by faulty dress and pernicious habits of life, and 
lastly by congenital malformations and accidental circumstances over 
which the patient has no control. The old saying of Hippocrates -was. 
" Propter uterum est mulier," and to a very great extent this is undoubt- 
edly true ; but during recent years the pathological changes occurring 
in the ovaries have attracted so much notice, and have thereby boon 
recognized as being far more pernicious than was formerly supposed — 



48 GENERAL CONSIDERATIONS UPON 

so frequent, indeed, that instead of "propter uterum est mulier," it 
might be more correct to say, " propter ovaria est mulier." In addi- 
tion, the formerly insignificant Fallopian tubes have, chiefly in con- 
sequence of the discoveries made by means of the surgeon's knife, 
attained an importance and a rank in female pelvic pathology even 
equal to, if not surpassing, those of the uterus and ovaries. Besides, 
the peritoneum lining the pelvic cavity has, by means chiefly of this 
same surgeon's knife, gained a position second only to that of the 
three organs already named. 

To begin with the uterus. In order that it should perform its func- 
tions efficiently and naturally it is essential, first, that its innervation 
and circulation should be normal ; second, that its structure should be 
unaltered in character and proportions ; and thirdly, that no decided 
and permanent change should have occurred in its position. An abnor- 
mal state developing in connection with any one of these essential con- 
ditions may derange the functional powers of this important organ, and 
demonstrate itself by symptoms which produce greater or less dis- 
comfort to the woman. If, as often happens, one of these conditions 
produces one or both of the others, and all occur simultaneously, the 
symptoms evoked are of course intensified and multiplied. Thus, after 
parturition, which may then be either premature or attended by more 
or less disturbance, the uterus does not return to its normal, ante-preg- 
nant condition — remains large, soft, congested, with its mucous mem- 
brane in a hyperaemic and hypersecreting state. Gradually this heavy 
organ drags upon its relaxed supports, which finally give way and the 
uterus drops out of place ; in the course of time, in consequence of the 
continuance of the uterine congestion, the areolar tissue between its 
muscular fibres is increased in quantity and becomes tough and inelas- 
tic ; instead of a soft, congested uterus, we now have a hard, almost 
cartilaginous organ, and instead of the freely-secreting and hypersemic 
uterine mucous membrane, there is an atrophic, bloodless endometrium. 
Now the displacement is of comparatively little importance, since the 
size of the uterus is so much less than at the beginning of the process. 
In accordance with the relaxation of one set of supports or the other, 
the uterus in these cases will fall downward, backward, or forward, and 
sometimes even siclewise, or by resting upon the floor of the pelvis the 
cervix may be bent and a permanent deformity of that part of the 
organ result. In consequence of this train of pathological conditions 
we may have sacralgia, bearing-down pains in the pelvis, leucorrhoea, 
and profuse and painful menstruation, not to mention the possibility 
of sterility. A frequent and now very commonly recognized primary 
cause of this chain of events is the occurrence of a laceration of the 
cervix, the truth of the statement being easily proved by the gradual 
restoration to health following surgical repair of the laceration and the 
subsequent treatment, step by step, of the other changes. Some have 
supposed that a displacement of the uterus in itself was a sufficient 
pathological change to produce decided subjective symptoms and to 
call for speedy relief. This belief is undoubtedly true as regards down- 
ward displacements and certain aggravated forms of backward displace- 
ment and of anteflexion, but modern, more extended observations have 



UTERINE PATHOLOGY AND TREATMENT. 49 

proved that a moderate form of anteversion or anteflexion and retro- 
version and retroflexion do not of themselves produce decided physical 
disturbance, but that the frequently accompanying congestive enlarge- 
ment and catarrhal condition of the endometrium are the real causes 
of the discomfort experienced by the patients. We believe that in the 
order of their frequency and importance the following primary patho- 
logical conditions must be considered to constitute the especial factors 
of uterine disease : 

1. Catarrhal inflammation of the lining membrane ; 

2. Prolonged congestion of uterine tissues ; 

3. Excessive growth of connective or muscular tissues. 

The first condition may be found in the virgin, in the married nullip- 
arous woman, and in the woman who has borne children. It may be 
the result of exposure to cold, of sudden arrest of menstruation, of over- 
exertion, in the virgin ; of the same causes, with that of excessive coition 
added, in the married nullipara ; and of subinvolution, too early rising, 
laceration of the cervix, in the parous woman. 

The second condition follows more or less closely upon the first, 
depends upon similar causes, and is intimately connected with them. 

The third condition is merely the last link in the chain, and the 
natural consequence of a long continuance of the first two. 

Whatever tends to produce and maintain any of these three primary 
conditions is likely to establish confirmed uterine disease. 

We will briefly review more in detail the individual agencies which 
ordinarily induce such a result : 

1. As we have already stated, in a very large majority of cases of 
uterine disease the first link in the morbid chain is subinvolution, 
which produces as direct consequences passive congestion, hypersecre- 
tion of the lining membrane, profuse menstruation, displacements, ster- 
ility, and interference by pressure with neighboring organs. 

2. A large number of cases arise from primary catarrhal inflamma- 
tion of the lining membrane of the uterus itself; beginning with this, 
there follows a hyperplasia of uterine tissue, displacements, menstrual 
disorders, and sterility. 

3. Disease not only of the neck, but of the body, and not only of 
the mucous membrane, but of the tissue proper of the organ, is often 
induced by laceration of the cervix, which results in eversion and the 
exposure of the tender cervical mucous membrane to friction and injury 
during coition and exercise. 

4. The development of benign or malignant growths, consisting of 
hyperplasia of one or more of the uterine elements, often changes the 
innervation, circulation, form, and size of the uterus and results in dis- 
placements, menstrual disorders, leucorrhoea, pelvic pains, mechanical 
interference with surrounding objects, and, in the case of malignant 
disease, a fatal issue. 

5. In a certain number of cases undoubtedly displacement of the 
uterus results in passive congestion, hypergenesis of tissue, dysmenor- 
rhea, endometritis, and sterility. 

6. As the result of acute flexion of the uterine canal the circulation 
of the organ is in some cases interfered with, passive congestion takes 



50 GENERAL CONSIDERATIONS UPON 

place, and dysmenorrhea ensues. Whether this dysmenorrhea can be 
called congestive or obstructive is still a matter in dispute. We believe 
that while a uterine canal may not in the intermenstrual period be so 
flexed as to prevent the exit of blood, still, that in the hypertrophic 
condition of the endometrium natural to the inception of menstruation, 
for the time being the swollen mucosa may prove a temporary obstacle 
to the exit of the flow, and thus cause an obstructive dysmenorrhoea. 

7. Under highly neurotic conditions of the whole system painful 
menstruation may occur, which is not in itself due to any pathological 
change in the uterus distinguishable by a physical examination. These 
are the so-called cases of neuralgic dysmenorrhoea. 

8. The uterine canal may be either so much narrowed or entirely 
closed as the result of congenital deformity or subsequent disease as to 
prevent the free exit of secretions and blood from the uterine cavity, 
and thus painful menstruation, inflammation of the lining membrane 
of the uterus, hsematometra, and possibly regurgitation through the 
Fallopian tubes, may ensue. 

9. Compression of the uterus may occur by large exudations of 
plastic material in Douglas's pouch or in the pelvic cellular tissue, in 
consequence of which the circulation of the uterus is obstructed and a 
bloody flow from the organ may take place, although it is not in itself 
diseased. 

10. In consequence of a general deranged state of the nervous sys- 
tem the genital organs may be kept in a condition of congestion and 
hyperesthesia, such as vaginismus, pruritus, and nymphomania, so as 
to simulate actual disease of those organs, or fissure of the anus or an 
inflamed bladder may exert a like influence upon the other pelvic 
organs. 

Any one of the above-named pathological conditions may exist 
alone in a given case or be associated with one or more of the others. 
Among the conditions which are commonly associated are subinvolu- 
tion, chronic endometritis, displacement, profuse or painful menstrua- 
tion. To find malignant disease of the uterus combined with fibroid 
growths is unusual, although a carcinome of the cervix, together with 
a fibroid of the body of the uterus, has been occasionally observed. 
In the great majority of cases in which uterine disease has existed for 
a greater or a lesser length of time the following conditions will usually 
be found present : 

1. The uterus will be larger than normal ; that is, either subinvo- 
luted or hyperplastic. 

2. A chronic catarrh of the endometrium exists. 

3. The uterus will be displaced. 

4. More or less laceration and eversion of the cervix is found. 

5. The ovaries and tubes will be more or less sensitive and enlarged. 
According as one or the other of these physical signs predominates 

the symptoms will vary and the treatment will need to be directed par- 
ticularly to it. In former years a great deal was taught and written 
about ulceration, granular erosion, and inflammation of the cervix uteri. 
Since the discovery of Emmet that the above conditions, at least in the 
parous woman, are due almost exclusively to a parturient laceration 



UTERINE PATHOLOGY AND TREATMENT. 51 

of the cervix, the causes, significance, and treatment of these lesions 
have been properly appreciated. We must not overlook the fact, how- 
ever, that erosion of the lips of the cervix in a virgin or nulliparous 
woman is a common result of chronic endometritis, both corporeal and 
cervical. 

The disease known to the older writers by the name of chronic metri- 
tis is nowadays no longer recognized as an inflammation ; in fact, such 
a pathological condition as a chronic inflammation does not exist : 
clinical, macroscopical, and microscopical investigations have demon- 
strated that the so-called chronic metritis is merely a gradual formation 
of new intermuscular cellular tissue, produced by the persistence of 
venous hyperemia and aggravated by the regular menstrual engorge- 
ments. Subinvolution of the uterus must necessarily be considered 
the most frequent starting-point of this so-called areolar hyperplasia. 
While this disease is in no sense dangerous or productive of any more 
than comparatively trifling discomforts to the patient, it is still of such 
frequent occurrence that we have thought it worth while to refer to it 
in this brief discussion of uterine pathology. We do not pretend to 
deny that an acute inflammation of the non-puerperal uterus may at 
times gradually develop the same subjective and physical signs as are 
found in areolar hyperplasia following subinvolution, but this occur- 
rence is, in our experience, so rare that we could almost number the 
cases on our fingers. 

Ovaries and Tubes, — The normal physiological recurrence of ova- 
rian congestion every four weeks as a premonition of the menstrual 
flow, if in any way arrested or interfered with, will produce a passive 
congestion, and ultimately a hyperplasia, of the stroma of the ovary. 
Any sudden or particularly active interruption of ovarian activity 
may produce even an acute inflammation of that organ. As the result 
of such interference pain more or less acute, more or less constant, may 
exist in the ovarian region, and the ovaries may gradually become 
enlarged, exquisitely tender, and may prolapse behind the uterus so as 
to be subject to injury during coition and defecation. Further, a con- 
tinuance of periodical ovarian congestion may result in the gradual 
enlargement of the Graafian follicles ■ and the ultimate production of 
ovarian tumors. Besides the local effects of the influence above named, 
the diseased conditions of the ovaries may make themselves felt in 
more or less distant organs by means of what is known as reflex action 
upon the nervous system ; thus an inflamed ovary may produce directly 
an irritable stomach, a hemicrania, a submammary neuralgia, and 
various other nervous symptoms. Painful and profuse menstruation 
may also be a result of ovarian congestion or inflammation. 

In consequence of any cause which may produce a catarrhal inflam- 
mation of the lining membrane of the uterus, the same membrane 
extending into the Fallopian tube may become involved, and catarrhal 
salpingitis with its significant pain and probable production of sterility 
may ensue later on; the catarrhal inflammation may assume a purulent 
character; the tube may become hyperplastic in all its elements: its 
purulent discharge may ooze out of the infundibulum : and a plastic 



52 GENERAL CONSIDERATIONS UPON 

peritonitis with adhesion and probable closure of the tube will take 
place. Finally, a gradually increasing accumulation of pus may occur 
in the tube, dilating it to many times its normal dimensions. In place 
of the pus clear serum or a bloody fluid may distend the tube. With 
the pathological conditions of the ovary and tube just mentioned it is 
obvious that sterility must simultaneously exist. 

Peritoneum. — Chiefly as a result of the tubal diseases above men- 
tioned the peritoneum lining the pelvic cavity becomes inflamed, its adja- 
cent folds agglutinated, and more or less firm adhesions form between 
them and the ovaries and tubes. Besides, large exudations of serum and 
plastic lymph occur, as the result of acute inflammation, into the 
pockets and recesses of the pelvic peritoneum, forming more or less 
appreciable and distinct masses which interfere with the normal mobilitv 
of the uterus and appendages, and ultimately are either absorbed or go 
to suppuration, or leave behind them indubitable traces of their pre- 
existence in the shape of adhesions and distortions of the pelvic organs. 
The importance, therefore, of the pelvic peritoneum as a factor in the 
production of sexual disease in the female is clearly demonstrated. 

Pelvic Fascia and Ligaments. — Chiefly as the result of parturi- 
tion, especially if difficult or frequently repeated, injury or relaxation 
of the pelvic fascia and ligaments is sustained, and in consequence of 
the absence of support given by these tissues to the uterus, bladder, 
and rectum, a dropping of these organs frequently takes place, and 
we find bladder, uterus, and rectum, either one or the other, individ- 
ually or all together, loosened from their normal attachments and more 
or less prolapsed. If in addition the superior supports of the uterus — 
namely, the folds of peritoneum known as the broad, retro-uterine, and 
vesico-uterine ligaments — are relaxed, nothing is in the way to prevent 
a complete extrusion of the organs occupying the pelvic cavity. 

Prognosis in Uterine Affections. — There is no organ of the body 
the diseases of which offer greater difficulties in prognosis than those of 
the uterus. So much depends upon the habits of the patient, the 
injurious influences to which she is exposed, and the faithfulness with 
which she follows out the directions of the physician that often very 
little can be predicted, very little promised with any certainty. The 
error into which the incautious practitioner is most likely to fall is that 
of predicting a cure at too early a period, and fixing some definite time 
for its accomplishment. The patient may declare that she and her 
friends will be satisfied even if the limit be fixed not by months but 
by years ; nevertheless, she is desirous of knowing when she may con- 
fidently expect a cure. The answer to this question, not in the lesser 
interest of the practitioner, but in the greater one of the patient, must 
often be that no such time can possibly be determined upon. In some 
cases it becomes necessary to state further that not only is the time, 
but the certainty, of complete cure doubtful — that local treatment will 
cause pain, may result in danger, and may absolutely aggravate the 
existing symptoms. 



UTERINE PATHOLOGY AND TREATMENT. 53 

Another point which influences prognosis is this : in the manage- 
ment of uterine diseases it is of primary importance that the prac- 
titioner should enlist the interest and co-operation of his patient. 
Should she be apathetic with regard to the result, or even, having 
begun treatment with enthusiasm, become disaffected from any cause, 
his duties will probably prove irksome, annoying, and fruitless. For 
this reason he should be cautious in urging with too great earnestness 
the adoption of local treatment. 

In view of this, and the additional fact that treatment may extend 
over months before a cure is effected, the physician should avoid all 
resources which by their uncleanness or disagreeable nature may dis- 
gust a refined patient or make her rather willing to bear her disease 
than the means adopted for its cure. If such means will be very 
likely to give relief, they should of course be employed ; but if, as is the 
case with many of them, their efficacy be extremely doubtful, they should 
not be insisted upon. For example, to give an exaggerated illustra- 
tion, if a lively, fastidious lady were called upon, for the relief of an 
endometritis which is not in itself very annoying, to forego society and 
spend most of her time in bed, to fill the vagina daily with a semi- 
solid mass of powdered linseed after the method of Melier, to rub mer- 
curial ointment over the hypogastrium, and have a weekly application 
of leeches around the anus, she would probably in time get tired of the 
treatment and lapse into the very state of apathy to which we have 
alluded. 

There is one class of cases in dealing with which we should espe- 
cially recommend that perfect frankness be observed. It may be rep- 
resented by a patient who has been persuaded by husband, mother, or 
friends, contrary to her wishes, to submit to treatment. She utterly 
repels the course to be adopted, is sure that it will do her no good, is 
unwilling to fulfil the directions left her for daily guidance, but yields 
under the assurance of her advisers that the treatment will be free 
from discomfort, give no pain, and will surely cure her in a few weeks. 
The physician, for the sake both of his patient and himself, should 
avoid joining in this deception. Stating the facts fully to her, telling 
her of the danger which neglect will involve, and of her duty under 
the circumstances, he should appeal to her reason, and decline to take 
charge of her case until she really desires his services. 

Reasons for the Frequency of Failure in the Treatment of Uterine 
Diseases. — That some uterine affections of non-malignant type are 
incurable cannot be denied ; but even putting these out of considera- 
tion, the fact is notorious that the local treatment of these diseases is 
not as successful in its results as we could wish. We now propose an 
investigation into the causes of this want of success. It appears to 
us that the most apparent and most constant of them may thus be 
summed up : 

Imperfect diagnosis ; 

Erroneous prognosis ; 

Inefficient or inappropriate therapeutics : 

Inattention to general management. 
Imperfect Diagnosis. — It is not rare to meet with instances in 



54 GENERAL CONSIDERATIONS UPON 

which physicians have, for months, treated cases of uterine disease 
concerning the nature of which they not only did not have a correct 
theory, but had no theory at all. Under these circumstances the most 
general practice formerly was to pass, about once a week, a solid stick 
of nitrate of silver up to the os internum — not to cure cervical endo- 
metritis, for that has never been suspected, but to do the best one can 
in the way of treatment when he does not know the nature of the dis- 
ease which he treats. We have no inclination to attribute this always 
to any intentional laxity of morale, but rather to indecision and aver- 
sion to creating a disagreeable issue with the patient. It is, however, 
impossible to deny the fact that such a course will sometimes be pur- 
sued by those who in the case of a diseased eye or inflamed knee-joint 
would not hesitate to confess, with the utmost frankness, their uncer- 
tainty and need of assistance. With uterine as well as all other dis- 
eases the diagnosis must be properly made before treatment can prove 
curative ; and in this field of practice, fully as much ■ as in others, 
honesty and sincerity should guide the practitioner. He who prac- 
tises deception here is surely no less culpable, although far more 
likely to escape detection, than the charlatan who makes it a rule 
of life. 

It is a matter for congratulation to the medical profession, as well 
as to poor, suffering women whose health and happiness are at stake, 
that year by year general practitioners are either acquainting them- 
selves more thoroughly with the details of pelvic disease in the female, 
or, recognizing their inexperience and want of skill, are acquiring the 
habit of taking such patients to specialists, in whose hands they can 
safely place their patient if they themselves do not feel competent to 
carry out the directions received from the consultant. The field of 
medicine has now grown so large that it is impossible for any man to 
master completely every one of its departments. The " universal 
specialist" is, in fact, an impossibility; hence Medicine has necessarily 
been divided into numerous specialties, each of which forms the life- 
study of a certain number of physicians, who, of course, are much more 
competent to diagnose and treat diseases coming into their specialty 
than any general practitioner can possibly be. True specialism, as it 
now exists, and very properly so, is a creation of the last twenty-five 
years, and chiefly since then have the greatest advances been made in 
medical science. 

Erroneous Prognosis. — Even if the diagnosis and treatment be 
correct, an erroneous prognosis as to time of cure may so sap the con- 
fidence of the patient as to send her to other counsel. And now she 
may run the gauntlet of theories and therapeutics. Her first attendant 
having recognized endometritis with resulting displacement, the second 
may treat the displacement alone as the origin of her symptoms. 
Passing into the hands of a third, she may be told that to check her 
profuse leucorrhcea would be to cure her disease, which the fourth 
might contradict, with the assertion that the uterine disorder was only 
a complication of oophoritis, which was the fountain of all her diffi- 
culties. 

Inefficient or Inappropriate Therapeutics may cause failure in cure 



UTERINE PATHOLOGY AND TREATMENT. 55 

even when a proper diagnosis and prognosis have been made. At 
times a course of local alteratives may be persevered in when the 
disease demands more general treatment. At others it is necessary to 
extend treatment into the cavity of the body, and not of the neck 
alone; and at others, still, to perform a trifling surgical operation to 
remove a difficulty which, unless removed, may keep up the disease 
indefinitely. 

The best results in the management of these affections will not fol- 
low a direct resort to treatment of the most prominent existing disease, 
but will very often be obtained by removal of its cause or the allevia- 
tion of its complications. Let us make our meaning clear by some 
examples. The physician examines and finds endometritis to exist 
with its usual symptoms, leucorrhcea, pain, menstrual disorders, etc. 
This affection may be the result of an antecedent displacement. If it 
be so, replacing and retaining in position the displaced organ should 
be the first step in treatment, as it was the first step in diseased action. 
Again, a patient has menorrhagia and prolonged menstruation, with a 
long, contracted cervix uteri. Obstruction to the ready escape of 
menstrual blood often so alters the lining membrane of the body of 
the uterus as to create these disorders. If the physician treat the 
symptom, he will surely fail in curing it, while success will attend his 
efforts if he remove the obstruction which prevents the uterus from 
emptying itself. 

So also with the complications which are excited by uterine disorders. 
A . patient is affected by cervical endometritis that in time produces 
hyperplasia, which by increasing uterine weight displaces the uterus. 
That organ, lying upon the floor of the pelvis, is injured by locomo- 
tion and coition, its lower segment is bathed in purulent leucorrhoea, 
and great pelvic pain annoys and harasses the patient. If the practi- 
tioner expects to cure her, let him, at the same time he treats the pri- 
mary disease, the endometritis, relieve a set of complications which, 
unless removed, will cause repeated relapses as often as he approaches 
the accomplishment of his end. 

One more example may be cited before concluding these remarks. 
A displacement of the uterus exists, and the practitioner knows that it 
has been due to one of two influences — either increase of uterine weight 
or loss of uterine support. Which was primary he cannot determine, 
for at the time of his examination both exist. To effect a cure it would 
be the part of wisdom not to limit treatment to one, but simultaneously 
to treat both by giving artificial support and diminishing uterine weight. 
Without being able to say which is the original disease and which the 
complication, he should endeavor to relieve both at the same time. And 
here, unfortunately, the patient is liable to come in contact with the 
personal prejudice of her attendant; he does not approve of pessaries. 
Why ? Because he has seen them do great damage ! Yet he does 
approve of splints, of the catheter, of anaesthesia, ami of opium ! Very 
likely he has not given an hour to the investigation of this important 
subject in his whole professional career. How often do patients come 
to those specially treating these diseases, after years of treatment from 
such prejudiced practitioners, with anteversion, retroversion, or slight 



56 UTERINE PATHOLOGY AND TREATMENT. 

prolapse, and, obtaining immediate relief, ask in surprise the significant 
question, Why was this not done long ago ? 

Every man is loath to acknowlege incapacity to patients who believe 
him to be possessed of all medical science : and in some of these cases 
for years the patient is allowed to bear suffering, inconvenience, and 
expense by reason of the vanity and incompetency of her physician. 

Until a few years ago surgical gynecology was a new departure, and, 
being frequently overdone, was of course subject to much severe and 
hostile criticism. In certain particulars the criticism may at present 
still be justified, but, all in all, the marvellous achievements of sur- 
gery in gynecology within the last decade have triumphantly swept 
away all opposition, and to-day, to be a gynecologist fully abreast of 
the requirements of the times, means to be an accomplished, a skilful, 
and a daring surgeon. Millions of women, who twenty years ago were 
allowed to go on suffering under tedious palliative treatment, have since 
been cured by the skilful and rational use of the knife, and probably 
the end is not yet. 

Inattention to General Management and Hygiene. — The statement 
which we often meet with, that the majority of the cases of uterine 
disease require no local treatment whatever, is a fallacy, based either 
upon strong prejudice against one of the most important modern im- 
provements in medicine or upon want of experience in such cases. 
But too much stress cannot be laid upon the advantages to be derived 
from constitutional treatment and the general management of these cases. 
We too often fail to insist upon rest, cessation of marital intercourse, 
quietude after applications to the uterus, and other points, a neglect 
of which may exert a powerful influence for evil and frustrate the 
effects of all that is done by local means. 

Every one who has had experience in the treatment of these disor- 
ders must have been struck with surprise at the wonderful improvement 
exerted upon cases which have long resisted local means, by a sea-voy- 
age, a visit to a watering-place, a course of sea-bathing, or a few months 
passed in the country. Not only is this improvement manifest in the 
general state of the patient ; it shows itself locally also, and in some 
cases complete recovery may be thus attained. 

It should not be forgotten by the gynecologist that chronic local 
disease is often caused by a general depreciation of the system. In 
some cases the lungs undergo chronic consolidation, which often 
goes on to phthisis ; in others chronic corneitis or granular lids occur ; 
while in others still cervical endometritis marks the altered consti- 
tutional condition. When such a result takes place the two states 
continue to react one upon the other. The depraved system increases 
the local disorder to which it has given rise, and the irritation, kept up 
by the latter, aggravates the degree of the former. This being true, 
it would evidently be irrational to treat one of the two existing patho- 
logical conditions without having due regard to the other. Some cases 
of endometritis, however, occur in women who are apparently in good 
health, and are usually the consequences of parturition or abortion. 
But cervical, and even corporeal, endometritis, the latter of which may 



THERAPEUTIC RESOURCES OF GYNECOLOGY. 57 

go on to villous degeneration, will generally be found to have engrafted 
themselves upon a depreciated system. 



CHAPTER IV. 

GENERAL CONSIDERATIONS UPON SOME OF THE MOST IMPORTANT 
THERAPEUTIC RESOURCES OF GYNECOLOGY. 

It is not our intention to devote a chapter here to the general con- 
sideration of the ordinary therapeutical resources of this department, 
but, as some of the most important of these should be especially con- 
sidered and described, we prefer to do so here, rather than scatter them 
in a desultory manner throughout the work, where some of them might 
escape notice. 

At the same time that the judicious practitioner should avoid routine, 
he should not allow himself to confound in his mind the two terms 
''routine" and "system," and, while no two cases should be treated 
exactly alike, a general plan will apply with greater or less exactness 
to many. 

General System of Diet and Exercise for Restoring the Deprecia- 
ted Nerve- and Blood-state ordinarily attendant upon the Pelvic Dis- 
eases of Women. — As a rule, these cases require a general tonic plan 
of treatment. There are, however, a few exceptions to the rule, such, 
for example, as cases in which the neurasthenia and spansemia so uni- 
versal as consequences have not as yet arisen, because the patients 
have not been long exposed to the pathological condition. 

The following are the directions which we give to patients for a 
general plan : 

1. While you are under treatment remember that a great deal will 
depend upon your cordial co-operation and intelligent endeavor to 
carry out instructions. 

2. Eat fresh animal food three times a day, and as much other 
nutritious food, such as bread, crushed wheat, potatoes, rice, eggs, etc., 
as you can. 

3. Between breakfast and the mid-day meal, the mid-day and even- 
ing meal, and upon retiring at night, drink a tumbler of milk or a 
teacupful of beef-tea or of mutton or chicken broth. 

4. Every morning upon rising, and every night upon retiring, take 
a sponge-bath of warm water strongly impregnated with table salt. 
about a teacupful to an ordinary basin of water. Then rub thor- 
oughly and briskly with a rough towel : the knitted tape towel is the 
best. 

5. After each bath exercise for ten minutes briskly with dumb- 
bells, the rowing-machine, or light calisthenic rods, breathing during 
this time freely and as deeply as possible. 



58 SOME OF THE MOST IMPORTANT 

6. Endeavor to sleep for nine hours every night and for one hour 
at mid-day every day remove the outer clothing, lie quietly in bed, 
remain entirely without occupation, and if possible sleep. 

7. Have an action by the bowels once in every twenty-four hours. 
If constipation exists, take a tablespoonful of this prescription every 
morning on waking in a half tumbler of cold water : 

1^. Magnesiae sulph., giv ; 

Ferri sulph., £ss ; 

Acidi sulph., dil., 3ij ; 

Aquae, 3xvj. — M. 

8. During menstruation keep very quiet, and at all times avoid 
violent muscular exertion and fatigue. 

9. Use every night and morning a copious vaginal injection of very 
warm water, by the method explained to you. 

10. Be sure that the clothing be loosely worn, and that all weight 
of skirts be carried upon the shoulders and not upon the hips. 

It is tiresome for a practitioner, seeing a large number of new 
patients daily, to repeat these directions to each. He is very apt too. 
even if willing to assume the labor, to forget some of them, and even 
if he do not the patient is very sure to do so. It is therefore very use- 
ful to have them printed upon a slip of paper, so that a copy may be 
carried home for reference and future guidance. 

Of course, in addition to these, special cases will require particular 
prescriptions and directions as to use of stimulants, etc. If the patient 
is to wear a pessary too, we are in the habit of giving another list of 
directions having special reference to the management of this, which 
will be given in connection with that subject. 

Pessaries. — Uterine pessaries hold a prominent position among 
surgical appliances as a means of procuring palliative and curative 
results. Like all other mechanical means which are powerful for good, 
they are capable of doing some harm. Their injurious consequences 
we would attribute, however, not to the instruments themselves, but 
to the improper manner in which they are very often used, and the 
carelessness with which they are allowed to remain in situ without 
observation. If splints were applied to broken bones and never 
examined until union was effected, their utility would soon become 
doubtful. Pessaries should be carefully watched, for they sometimes 
create cellulitis, peritonitis, and vesico-, recto-, and utero-vaginal fistulae. 
In some cases they have been known to pass completely out of the 
vagina into the rectum or bladder. Some years ago a case entered 
the service of Prof. L. A. Sayre of the Bellevue Hospital Medical Col- 
lege, presenting very obscure symptoms of uterine disease. Examina- 
tion proving that some foreign substance existed in utero. Prof. Sayre 
dilated the cervical canal, and extracted a globe pessary which had 
migrated from the vagina into the uterus, and been retained there for 
a length of time. 

Whatever pessary be employed, it should sustain the displaced uterus 
without creating pain or discomfort. Should any such inconvenience 



THERAPEUTIC RESOURCES OF GYNECOLOGY. 59 

be produced, it should be at once removed, for the most violent cellu- 
litis and peritonitis may result. While a pessary is kept in the vagina, 
cleanliness should be secured by daily vaginal injections, and at inter- 
vals, not exceeding two months, it should be removed, examined, and 
reintroduced. At such times a specular examination should always be 
made, since possible erosions produced by the pessary cannot be detected 
by the finger alone. 

One of the difficulties attending the use of these instruments in gen- 
eral practice unquestionably arises from the fact that a great deal of 
experience is necessary before any one can use them with certainty 
of accomplishing good results. But another is due to the practitioner 
having only a small supply from which to choose. He who habitually 
employs these articles should have at his disposal a large and varied 
assortment, and should possess sufficient mechanical ingenuity to 
mould and adapt them to the special requirements of cases which 
may present themselves. The vulcanite pessary may be given any 
shape after being heated, and metallic ones may be readily moulded 
by the fingers. 

Whether a suit for malpractice has ever arisen on account of injury 
done by a pessary we cannot say, but we can easily imagine such a 
source of litigation. Every practitioner should bear in mind that injury 
done by a pessary does not argue ignorance on the part of its intro- 
ducer. When one removes, as every gynecologist must often do, a pes- 
sary from a position in the pelvis in which it has become imbedded, and 
finds, as its result, a ragged, ulcerative tract existing, he is very apt 
hastily to conclude that the instrument was improperly applied. This is 
by no means always true. We have repeatedly removed pessaries under 
these circumstances which had been introduced by the most competent 
gynecologists. How common it is to find a pessary which one has care- 
fully introduced turned completely upside down at the end of a week ! 
The migratory and evolutionary performances of the vaginal pessary 
are truly wonderful. These facts being recognized and admitted by all, 
the evident deduction is that it is unjust, as it is unprofessional, to 
expose to a patient, at the expense of an absent colleague, every lesion 
which these difficult instruments have created. To tell a patient that 
the instrument she wears has made a deep ulcer in the vagina is to tell 
her that her attending physician has been guilty of a gross blunder ; 
for "ulcer," in the popular mind, means anything that is frightful in 
the way of lesion, from erythema to carcinoma. And, although the 
statement is literally true, he who makes it knows that the same acci- 
dent has happened to himself many times, that a week of rest will 
entirely efface it, and that no real damage has resulted to the patient 
from its occurrence. 

In spite of all its attendant evils, the use of the pessary is. as we 
have said before, one of the most important points in gynecology, and 
every practitioner of that art should make it a faithful, special, and 
constant study. We confess that when we are told, as we sometimes 
are by physicians, that they never use pessaries, because they are so 
strongly prejudiced against them, the question always arises in our 
mind, Then how and why do you treat uterine diseases? How pes- 



60 SOME OF THE MOST IMPORTANT 

saries can be dispensed with is to us one of the unfathomable myste- 
ries of gynecological practice= And why any one should practise an 
art and ignore a • means which, properly mastered, constitutes one 
of the most powerful and reliable of its resources, is equally incompre- 
hensible. 

We think it an excellent plan for the physician who has inserted 
a pessary to give to the patient some such written directions as those 
which follow, urging her, in case of trouble from the instrument, to 
refer to and closely abide by them : 

1st. You are wearing a pessary. If it give you pain, pass your 
finger into the ring which you will feel and draw it away. Do not 
mind a little discomfort in doing this, but do it without fail. 

2d. If after this you suffer pain, go to bed and send for a physician. 

3d. Every night and morning douche the vagina thoroughly with 
from two to four quarts of hot water, using a fountain syringe and a 
douche-pan specially designed for the purpose. The water should be 
as warm as you can comfortably bear it. 

4th. Wear your clothing as loosely as possible, using "skirt sup- 
porters," and not wearing tight corsets. 

5th. Keep the bowels regular, securing one action every day. 

6th. Avoid, as much as possible, going up stairs, lifting heavv 
weights, using the sewing-machine, and riding in a rough vehicle. 

Tth. Lie down for an hour at mid-day every day, and keep very 
quiet at menstrual periods. 

8th. Remember that attention to these directions will have an 
important influence on your recovery. 

Precautions to be Uniformly Observed in Operations upon the Sexual 
Organs of the Female, for the Prevention of Septic Infection. — One of 
the greatest achievements of modern pathology has been the discovery 
of the ao-encv of certain families of lowly-organized funo-i and micro- 
cocci in the production of diseased states which the humoral pathology 
of the olden time had traced to the blood. Although the subject, born 
only twenty years ago, is still in its infancy, a great deal has already 
been accomplished in reference to it, and it is not too much to hope 
that the path has been struck which is destined to lead to an elucidation 
of the causes of contagion and infection. Those who were chiefly 
instrumental in establishing our knowledge upon this point are Vir- 
chow, Rindfleisch, Recklinghausen, Hueter, Yogt, Klebs, and, of 
recent years, Pasteur and Koch. 

The experiments and observations on the origin, growth, and dis- 
semination of the various fungi and micrococci which are supposed to 
produce many infectious and contagious diseases, such as septicaemia, 
diphtheria, scarlet fever, yellow fever, cholera, etc., have been mainly 
carried on with the thoroughness and perseverance peculiar to that race 
in the laboratories of the German universities. While this whole sub- 
ject may still be said to be more or less unsettled, and while in our 
minds it is still a question for future investigations permanently to 
decide (to put it, perhaps, a trifle strongly) whether the germs produce 
the disease or the disease the germs, still, the very recent observa- 
tions of Pasteur and Koch would seem to indicate that some dis- 



THERAPEUTIC RESOURCES OF GYNECOLOGY. 61 

eases at least are directly produced by certain noxious principles 
which, once introduced into the system, grow and spread and are 
transmissible to other living bodies. Although the germ theory 
had been foreshadowed for some time previously, it is chiefly due 
to the antiseptic teachings and practice of Sir Joseph Lister that 
attention was so forcibly drawn to the dangers incurred by every 
person afflicted with an open wound in contact with a vitiated atmo- 
sphere or with unclean instruments, fingers, or dressings. His device 
was to protect the open wounds by a spray of carbolic acid, under which 
all operating and dressing was performed ; hands, instruments, sutures, 
dressings were all cleansed and immersed in a similar solution of car- 
bolic acid. The results obtained were wonderful, and wounds healed 
by first intention, the like of which formerly in the same wards had 
either suppurated or become actually septic. In the course of time 
original and progressive minds came to the conclusion that as carbolic 
acid was, after all, not a real germicide, something else than this 
chemical agent must be the reason for the immunity from septic infec- 
tion achieved by Lister's method ; and in the course of their investi- 
gations they chanced upon an agent which, while in large doses a violent 
poison, is in weak solutions a powerful germicide — namely, corrosive 
sublimate, which in a solution of 1 : 10,000 is found to destroy the 
vitality of the bacteria, which thrive in even strong solutions of car- 
bolic acid. Hence, during the last ten years solutions of the bichlo- 
ride of mercury of varying strength have been the sheet-anchor of all 
surgeons who wish to be perfectly sure against the septic infection of 
their patients. On acccount of its possible toxic effects if absorbed too 
freely by the system where large wounded surfaces are to be brought in 
contact with the agent, solutions not stronger than 1 : 5000 are now used. 
The hands of the surgeon, however, are usually immersed in a solution 
of 1 : 1000 as often as may be required during an operation ; and 
instruments, because they are tarnished by sublimate, are kept in a 3 
per cent, solution of carbolic acid. Some of our most progressive 
surgeons contend that the use of poisonous germicides is entirely 
unnecessary, and that simple boiled or distilled water, with perfect 
cleanliness of hands, instruments, dressings, sponges, and everything 
connected with operator and patient, amply suffices to prevent septic 
infection. We admit the probable correctness of this view : at the 
same time we have thus far felt that absolute security was best attained 
by impressing upon the minds of assistants and nurses the scrupulous 
observance of strict antiseptic rules governing the use of poisonous solu- 
tions. Distilled and boiled water may be thoroughly sterilized, but In- 
standing it may again become infected. A solution of corrosive sublimate. 
even if very dilute, Avhether freshly prepared or not, always retains its 
germicide properties. Of course, in no instance should such a poison- 
ous solution, no matter how dilute, be freely poured upon so large an 
absorbent surface as the abdominal cavity. When it is necessary to 
wash out the abdominal cavity, we use either warm boiled distilled 
water or a solution recommended by Thiersch containing S parts oi' 
boracic acid and 1 of salicylic acid to 1000 parts of water. Unques- 
tionably, the essence of Lister's teachings and of the present practice 



62 SOME OF THE MOST IMPORTANT 

of antisepsis is the scrupulous observance of cleanliness in everything 
connected with the surgeon, the patient, and her surroundings. These 
principles are now so well understood and so universally accepted that 
even in the crowded hospitals septic infection is a rare occurrence, and 
where formerly whole wards would be infected with septicaemia, pyaemia, 
hospital gangrene, and prolonged suppuration, at present even the 
largest and most exposed wounds heal without rise of temperature. 

Let the gynecological surgeon keep constantly before his mind the 
fact that uncleanliness goes hand in hand with bad, and cleanliness with 
good, surgery. Simple as this agency seems, it is the sole one upon 
which rests the greatest advance of modern surgery. Emmet says, 
truly, " Many a woman's death-warrant is carried under the nails of 
her surgeon." Many years ago a humorous medical writer, half in 
jest, elevated the tongue-scraper to a place of dignity in the treatment 
of dyspepsia. The nail-brush, in serious earnest, deserves such a posi- 
tion as a prophylactic of lymphangitis and septicaemia. 

The following rules should always be observed in operating on the 
female genitalia : 

1st. Before and after every operation wash all instruments in very 
hot carbolized water, and during every operation keep all instruments 
immersed in carbolized water. Sutures and ligatures, if of silk, are 
boiled in a dilute solution of corrosive sublimate, and kept immersed 
in the same until used. Catgut is soaked in oil of juniper and pre- 
served in alcohol. Silkworm gut is treated in the same manner as silk. 

2d. In all laparotomy operations observe scrupulously the directions 
given for sterilizing instruments, sponges, dressings, as well as clothes 
and hands of operator and assistants. The carbolic-acid spray intro- 
duced by Lister is no longer employed. 

3d. Always bathe denuded surfaces both before and after apposition 
by suture with a solution of 1 : 10,000 of corrosive sublimate. 

4th. Always destroy sponges used in an operation which admits of 
the possibility of their being contaminated by septic fluids, and when 
they are employed a second time always have them boiled in a solution 
of bicarbonate of soda, then immersed in a weak solution of perman- 
ganate of potash, and preserved in boiled carbolized water. 1 

1 Methods of Sterilizing Gauze, Sponges, Silk, Silkworm Out, and Catgut, in use at Mt. 
Sinai Hospital. — Gauze: Wide-mesh cheese-cloth. Any dry -goods store, at about three 
and a half cents a yard. Cut into convenient pieces. Then take one pound of common 
soda to twenty yards of gauze, and sufficient boiling water to cover. Leave in this 
solution twenty-four hours. Wring, wash in cold water. Then for forty-eight hours 
in bichloride 1 : 1000. Wring, dry, fold. 

For carbolized gauze use 5 per cent, carbolic in place of the bichloride. 

Iodoform Gauze : Take Iodoform, % ss ; 

Glvcerin, ^ ss ; 

Bichloride sol. (1 : 1000), gt. j. 

In this mixture soak 10 vards of bichloride gauze prepared as above, wring, and then 
fold. 

Silkworm Gut and Silk: Boil for two hours in 1 : 500 bichloride. Keep in 1 : 1000 
bichloride (alcoholic) sol. Silkworm gut may be reboiled any number of times. 

Catgut : Common commercial catgut. In ether twenty-four hours, changing the 
ether three times. Then forty-eight hours in 1 : 100 bichloride sol. (alcoholic). Keep 
in 95 per cent, alcohol. 



THERAPEUTIC RESOURCES OF GYNECOLOGY. 63 

5th. After all operations upon the uterus, douche the vaginal por- 
tion of the organ with carbolized water, and if hemorrhage is appre- 
hended, tampon tightly for twenty-four hours with antiseptic cotton. 
This being removed, syringe the vagina with carbolized water at short 
intervals (two or three times daily). 

6th. After operations on the pelvic organs, irrigation of the vagina 
with carbolized warm water is required only if there is a discolored or 
offensive discharge. It is well to prevent the introduction of septic 
germs from without by covering the vulva with a pad of sublimate 
gauze, which is to be changed as often as soiled. 

7th. If absolutely necessary after operations, give morphine hypo- 
dermically to quiet pain and nervous excitement ; but avoid doing so 
if at all posssible after laparotomies. 

8th. Before all grave operations, if the patient is weak or anaemic, 
give an ounce of whiskey and ten or fifteen grains of quinine. 

9th. Before every operation let the operator and his assistants cleanse 
and disinfect not only the part to be operated, but also their own hands 
and arms, in order that every possible suspicion of septic infection may 
be removed. 

10th. As a rule, avoid even trivial operations, unless good reason 
for doing otherwise exist, for a few days before and after menstruation. 
Still, we have repeatedly performed laparotomy on patients who began 
to menstruate unexpectedly on the day fixed for the operation, or in 
whom menstruation came on immediately after the operation, and have 
in no way found recovery retarded by the coincidence. We have merely 
used the precaution of keeping the vagina sealed as hermetically as 
possible by a sublimate gauze pad over the vulva. 

While undoubtedly many wounds heal promptly under the most 
unfavorable circumstances, there can be no doubt that, chiefly in large 
hospitals, a careful observance of the above rules will result in an almost 
complete immunity from septic infection. Whether these splendid results 
are due to the employment of germicide agents, or whether they are to 
be attributed to the scrupulous cleanliness and attention to minute details 
in the dressing of wounds which are the outcome of modern antiseptic 
practice, we do not pretend to say : the fact remains that since the 
promulgation of Lister's doctrines a complete revolution, to the great 
benefit of patient and surgeon, has taken place in the management of 
wounds and in the results achieved by surgery. The surgeon who 
nowadays would omit the antiseptic precautions briefly detailed in 
the foregoing lines would be justly considered far behind the times 
and culpably neglectful of the best interests of his patients. 

Even in ordinary examinations of the uterus the antiseptic idea 
should always be kept in mind. The plan which we follow, there- 
Prepared Rubber Tissue: Cut into strips and wash in 1 : 1000 bichloride. Keep in 
same solution. 

Sponcjes: Common Florida. $1.20 a pound by bale (about one cent a piece) : used 
only once. Wet with water to expand; then dry. Beat thoroughly with mallet. 
Hydrochloric acid 8 per cent, for eight hours. Wash in cold water; wash in warm 
soapsuds (green soap h pound to water 1 gal.) ; wash in cold water to clear of soap. 
Keep in carbolic 5 per cent., changing every four weeks. 

(Furnished by Dr. Southgate Leigh, House Surgeon. — P. F. 31.) 



64 SOME OF THE MOST IMPORTANT 

fore, is this : Every day our office-nurse pours boiling water upon 
all the instruments ordinarily employed, such as speculum, probe, 
sound, tenaculum, depressor, etc., washes them carefully with soap, 
and rubs them bright with sapolio. They are then kept immersed 
in carbolized water during examinations. After every examina- 
tion the instruments used are again washed with soap, rapidly rubbed 
bright, and immersed in a fresh supply of carbolized water. After 
every examination the examiner's hands are carefully washed with 
soap in very warm water, the nail-brush freely used, and just before 
another examination they are rinsed in the carbolized water in which 
the instruments are brought in. The fingers and all instruments intro- 
duced either into the vagina or uterus are lubricated with carbolized 
vaseline, carbolic soap, or soft soap thoroughly carbolized. In these 
examinations absorbent cotton, held in a pair of dressing-forceps like 
those shown in Figs. 2 and 3, should be made to replace sponge, which 
is so much more likely to carry contagion from one patient to another. 

Fig. 2. 




Thomas's Dressing-Forceps. 
Fig. 3. 




Munde's Uterine Dressing-Forceps. 

That patients are at times injured by want of proper hygienic pre- 
cautions on the part of physicians we feel assured by personal obser- 
vation. That the contamination of women through their criminal 
ignorance or carelessness is not much more frequent is a matter of 
unceasing amazement to us. Every gynecologist should feel two 
things very sincerely with reference to his daily systems of examina- 
tions : 1st. That he would be willing to have his own female relatives 
exposed to all the risks of contagion to which he exposes his patients ; 
and 2d. That he would at any time willingly submit his methods to 
the critical investigation of a jury of his peers as far as concerns 
cleanliness and hygiene. 

After operations where it becomes necessary to have the bladder 
evacuated by the catheter the precaution should always be observed of 
dipping the catheter in carbolized water and smearing it with carbol- 
ized oil or vaseline before its introduction. A neglect of this often 
results in prolonged vesical trouble which might readily have been 
avoided. A further useful precaution is to have the vestibule cleansed 
with a pledget of cotton dipped in a weak solution of corrosive subli- 
mate before inserting the catheter, and always to insert the latter by 
sight instead of by touch, in order to avoid carrying foreign matter 
into the bladder, whereby a vesical catarrh might be excited. 

Vaginal Injections. — There is no agent in the treatment of diseases 



THERAPEUTIC RESOURCES OF GYNECOLOGY. 65 

of the pelvic viscera which possesses greater value than this, and yet 
none which has been used from time immemorial in a more unsystematic 
and desultory manner. Until the appearance of Scanzoni's work, now 
over thirty years ago, very small amounts of fluid were used, not nearly 
enough to wash out the vaginal canal thoroughly, and the little piston 
syringe employed -for the purpose, and holding only about an ounce, 
was utterly insufficient. Scanzoni taught us the important lesson that 
copious vaginal injections should always be employed where this method 
was resorted to, and gave us several very excellent plans for using 
them. This was an important step in advance. Since that time 
Emmet has done a great deal to systematize the matter, and introduced 
a method which we shall lay before the reader. His method is based 
upon the following deductions : 

1st. That no patient can use vaginal injections efficiently herself, 
but must have them administered by another ; 

2d. That for them to be effectual the patient must lie upon the 
back with the hips elevated ; 

3d. That a copious flow over the vaginal surface of water varying 
in temperature from 100° F. to 110° F. is most appropriate for all 
cases in which congestion exists ; 

4th. That cold water thus employed is hurtful by causing first vas- 
cular contraction and afterward dilatation, while hot water produces 
first expansion and then contraction. 

" The injection," says he, " can be better given to the patient after 
she is undressed for the night and in bed. She should be placed near 
the edge of the bed with the hips elevated as much as possible by the 
bed-pan, and a small pillow under her back, the lower limbs being 
flexed. Her body must be covered to protect her from cold, and her 
position made perfectly comfortable : whenever the bed is a soft one, 
for the purpose of keeping the hips elevated, a broad board should be 
placed under the pan to prevent it from sinking into the bed from the 
weight of the patient. The vessel of hot water is placed on a chair 
by the bedside, and the nurse passes the nozzle of the syringe into the 
vagina over the perineum, directing it along the recto-vaginal wall 
until it has reached the posterior cul-de-sac. The water must be thrown 
in at first very carefully, until the vagina has become distended." 

In hospital practice there is no method as good as this carried out in 
all its details, but in private practice every one must see the difficulties 
which will attend it. Dr. Emmet says that " few women are so 
situated as to be unable to get some one to administer the injections 
properly." We would alter the sentence, making it read, " few women 
are so situated as to be able;" for a lady does not like to call upon a 
servant to perform so delicate a task for her, nor is she willing either to 
impose it upon an equal or to bear the heavy expense of having a pro- 
fessional nurse visit her daily. Under these circumstances we employ 
the following plan : The patient places a pillow under the edge of her 
bed, and an empty tub upon the floor under it. She then covers the 
pillow by a piece of India-rubber cloth which drapes into the tub. 
Then, putting two chairs, one on each side and a little in front oi' the 
tub, she places a small table in front of these, and upon this another 



66 



SOME OF THE MOST IMPORTANT 



Fig. 4. 




Douche-Pan. 



chair. Upon the chair which stands on the table a tub containing 
about two gallons of hot water is now put, near the bottom of which 
has been inserted a spigot to which a long rubber tube is affixed, which 

ends in a vaginal nozzle. The patient now 
lies upon the bed, the pelvis elevated by the 
pillow, places her feet upon the chair, covers 
her limbs with a shawl or blanket, touches 
the spring — an ordinary clothes-pin or safety- 
pin makes a good one — which controls the 
flow, and the water bathes the vagina, and, 
running out, is conducted by the India-rub- 
ber cloth into the tub. 

Here the only articles purchased are the 
tub with the spigot and tube attached, and 
a yard of India-rubber cloth, which are in- 
expensive. The patient will have every- 
thing else in her chamber, and very little 
trouble attaches to the method, which is 
certainly an efficient one. Very conve- 
nient and inexpensive round or oblong 
douche-pans of zinc, which hold several 
quarts of water, are now made, on which the patient can lie comfort- 
ably while the water flows into the vagina from a fountain syringe 
suspended near by. The use of a nurse is thereby rendered quite 
unnecessary. 

While we admit the great value of Emmet's method, we do not by 
any means admit his postulate, that " not the slightest advantage is 
received from them (vaginal injections) when administered with the 
patient in the upright posture, or, as is the usual method, while seated 
over a bidet." Thus administered, they are less effectual than in the 
method described, but still they do a great deal of good. While a 
patient is travelling, or in cases where injections are required only for 
cleanliness, they may be relied upon to do very good work, and we 
therefore describe the method of employing them : Placing in a tub 
from one to two gallons of water, at as high a temperature as proves 
comfortable to the patient, she may sit over it upon 
a board placed across it or upon a stool placed in 
it, and inject the water by means of a syringe. 
The most convenient syringes for the purpose are 
the Essex and Davidson's. Both of these are 
provided with a stem about five inches long, which, 
being introduced into the vagina and carried up 
so as to touch the cervix, throws, when the ball of 
the instrument is compressed by the disengaged 
hand of the patient, a steady stream against it. 
By this means a stream of warm water is made to pour over the cervix 
for from twenty to thirty minutes, according to the amount of fatigue 
which the use of the instrument causes the patient. Still, for the pro- 
longed use of hot vaginal douches in the treatment of pelvic congestion 
or inflammation, we think the irrigation or fountain syringe, with the 



Fig. 




DAVIDSON RUBBER CO. 

Davidson's Syringe. 



THERAPEUTIC RESOURCES OF GYNECOLOGY. 67 

round bed-pan just described, both of which permit the free douching 
of the vagina with large quantities of water with little inconvenience 
and no pain to the patient, to be absolutely essential to any permanent 
benefit. 

Warm water is the best, as it is the simplest, most attainable, and 
cleanest, of all the emollients which can be used for this purpose. But 
it may easily be medicated by the addition of laudanum, half an ounce 
to the gallon, infusions of linseed, poppies, hops, bran, slippery elm, 
starch, hyoscyamus, conium, or farina, or by the addition of glycerin, 
one ounce to the gallon, lime-water or tar-water, both of which last are 
often very soothing to vaginitis that may exist as a complication. 

A few words are essential in reference to the nozzle which should 
be used in giving these injections. No amount of care will prevent the 

Fig. 6. 




Vaginal Syringe Nozzle, with reverse current. 

injection of fluid into the uterine cavity unless the nozzle be properly 
constructed. Sometimes where the cervix is lacerated or the cervical' 
canal dilated the patient will carry the instrument directly into the os 
externum and inject a large amount of fluid into the uterus. Such 
an accident is followed by violent uterine contractions and the probable 
passage of a portion of the liquid into and perhaps through the Fal- 
lopian tubes ; and this often results in a degree of pain w T hich almost 
causes collapse, and sometimes even in pelvic peritonitis. This acci- 
dent can always be prevented by having the nozzle of the syringe made 
with a reverse current, as represented in the diagram. We have for 
many years employed those made of hard rubber, and it seems to us 
that, in view of the fact that serious accidents sometimes follow the use 
of nozzles with direct jet, the precaution of reversing the current should 
always be observed by instrument-makers. 

The Tampon. — Had Sims's method of uterine examination done 
nothing else than lead to the proper manner of using the vaginal tam- 
pon,' it would have done by that alone a vast deal of good. Before its 
introduction the use of the tampon was a painful, uncertain, and inef- 
ficient hemostatic method. Since the use of Sims's speculum it has 
become an easy, painless, scientific, and most effectual means for pre- 
venting and checking hemorrhage from the non-pregnant uterus. The 
operator in gynecology who does not understand the modern method 
of tamponing the vagina, and who still relies upon the introduction by 
the fingers of a " kite-tail tampon," a silk handkerchief, pieces of cot- 



68 SOME OF THE MOST IMPORTANT 

ton, or this combined with sponge, etc., surely does great injustice both 
to his patient and himself, and fails to check the hemorrhage. 

In speaking of the vaginal tampon a recent writer 1 says: "It is 
a barbarous, slovenly, unscientific proceeding, and is generally based 
upon incompetence and instigated by terror. If hemorrhage be issuing 
from a closed os, it may be plugged with a sponge tent, in order that 
the source may be afterward reached. But if the cause of the hemor- 
rhage be known and be irremovable, the treatment should be to inject 
the uterus with acetic acid, or even with some salt of iron, though the 
latter is a proceeding accompanied by terrible risks." We quote this 
to say how entirely we dissent from it. The tampon properly applied 
is not only a simple, cleanly, and painless procedure : it is safer, more 
efficient, and more scientific than the alternatives here suggested. 
Above all things, avoid injecting solutions of iron into the uterine 
cavity : they form clots which are likely to decompose and cause 
sepsis, are difficult of removal in any case, and the vagina and uterine 
cavity become so contracted as to render future manipulations difficult. 
And also avoid packing the vagina with tampons soaked in solutions of 
iron, which contract the vagina and cause exfoliation of its epithelium. 
Only in cases of an exposed bleeding surface, as in cancer of the cervix, 
may a tampon soaked in a solution of liquor ferri persulphatis in gly- 
cerin or dipped in powdered persulphate be placed against the bleed- 
ing surface, the vagina being thoroughly protected by dry tampons. 

The patient being placed upon a table upon the left side, Sims's 
speculum is introduced and held by an assistant, while with sponges or 
rolls of cotton the surgeon removes from the vagina all mucus and blood- 
clots which may exist there. Upon a plate near him have been placed a 
number of thick disks of carbolized cotton, some soaked in a saturated 
solution of sulphate of alum or copper, and others simply saturated with 
water. All superfluous fluid has been squeezed out by pressing these 
disks between cloths. Taking up in the dressing-forceps one of the 
disks which has been saturated with an astringent, the surgeon packs 
this behind the neck of the uterus ; then alongside of this he places 
another, holding the first one well in place, meantime, by a rod of 
whalebone or other similar substance until the second is placed. In 
this way piece after piece is packed away until a collar is placed around 
the neck of the uterus which extends to a level with the os externum. 
Then this part is covered with more astringent cotton, which is packed 
into place and held there by pressure from a rod, and simply wet cotton 
is packed upon it until the vagina has been filled to within an inch of 
the vulva, when a piece of soft dry cotton is made to hold the more 
efficient upper tampon in position. The lower portion is now carefully 
pushed away from the urethra, and, a dry soft towel being laid over the 
vulva, a T bandage is applied. 

Such a tampon is a safe hemostatic agent. After operations upon 
the uterus or cervix, and occasionally upon the vagina, it proves a most 
certain preventive of hemorrhage. As a means for checking hemorrhage 
already fully established it has no equal in value in gynecological surgery. 

When it is necessary to remove this tampon, which may be left in 
1 Lawson Tait, Diseases of Women, 1877. 



THERAPEUTIC RESOURCES OF GYNECOLOGY. 69 

position for twenty-four or even thirty-six hours, the following method 
should be adopted : The Sims speculum should be gradually introduced, 
and each piece of cotton as it becomes visible be caught by a tenac- 
ulum or dressing-forceps and pulled out, until the last piece is removed. 
The vagina, having been thoroughly cleansed with cotton dipped in 
carbolic or sublimate solution, is retamponed in the same manner, 
provided danger of hemorrhage still exists. 

Since the introduction of iodoform into surgical practice, iodoform 
gauze in long strips forms a very efficient substitute for the disks of 
cotton formerly employed ; it packs well and tightly, causes coagulation 
of blood, and remains perfectly sweet even as long as a week. As soon 
as saturated, the iodoform-gauze tampon, like any other form of tampon, 
should be removed, as it has outlived its usefulness as a hemostatic. 

Means for controlling the temperature after operations and during 
pathological conditions developing in gynecology. 

A rise of temperature exceeding one or two degrees always means 
some pathological condition Avhich should be inquired into, and ivhen 
discovered if possible removed. Reaction, constipation, acute inflam- 
mation, and septic absorption may each, in rising proportions, cause 
an increase of temperature which will usually be higher near the seat 
of the cause than at some distant portion of the body. While a rise 
of temperature of from one to two degrees may not necessarily mean 
anything serious, it should certainly not be overlooked, and if possible 
be removed. A constant higher temperature, above 103° F., contin- 
uing through a period of a week or more is sure to depress the vital 
energies by consuming not only the strength which is derived from the 
nourishment taken, but by also sapping the central nerve-forces ; there- 
fore a prolonged high temperature may undoubtedly be said eventually 
to kill. For the purpose of preserving the strength of the patient, 
preventing the undue consumption of nerve-power, and making the 
patient more comfortable, it must always be our object to keep the 
temperature as much as possible within physiological bounds, having 
first satisfied ourselves, of course, as to the cause of the rise. Nat- 
urally, it would be illogical and unwise to deprive ourselves of the proofs 
furnished by various rises of temperature, which would aid us in mak- 
ing a correct diagnosis, by lowering it before the diagnosis is made. 
When the last edition of this book was written a method had come into 
vogue, which was really a revival of an old-time practice fallen into 
disuse, of reducing high temperature, chiefly after grave operations, by 
keeping the body immersed in more or less cold water, the patient being 
placed on a rubber cot and enveloped in sheets which were kept drenched 
by a slowly-flowing stream of water. Undoubtedly, this method was 
extremely effectual in reducing temperature, but, unfortunately, many 
patients, particularly emaciated and debilitated women, often suffering 
from the shock of a prolonged and dangerous operation, could not with- 
stand the steady lowering of temperature thus induced, and sank under 
the treatment. Gradually this method has been abandoned, having been 
replaced by various newly-discovered chemical agents which, with very 
much less trouble, and if carefully watched with scarcely any detri- 
ment to the patient, are capable of reducing temperature quite as 



70 THERAPEUTIC RESOURCES. 

rapidly and effectually as the cold-water affusions. Therefore in recent 
years we have relied almost entirely upon antipyrine, antifebrin, and 
phenacetin for this purpose. It is true, these agents, particularly anti- 
pyrine, have a certain depressing influence upon the heart ; hence we 
rarely employ the first remedy when there is any indication of cardiac 
debility ; but by not using too large doses, not more than ten grains 
at the time, and by perhaps combining them with some cardiac stim- 
ulant, such as caffeine or strophanthus, and by watching the effects 
carefully when repeated, we have been able thus far to avoid any 
unpleasant results. Ten to twenty grains of one of these agents will 
usually reduce the temperature two to three degrees, make the patient 
comfortable, give her a good sleep, and renew her strength to battle 
with the disease. That is all we ask of these antipyretics, depending 
upon other and more potent remedies to relieve and cure the cause 
of the fever. We have thus for weeks kept in check the daily-recur- 
ring high temperature in cases of puerperal septicaemia, sustaining the 
patient's strength by stimulants and nutrients until the septic poison 
was eliminated, and with it the temperature dropped permanently 
to its normal rate. 

The possible assistance of the cold wet sheet wrapped about the 
trunk and renewed as often as it becomes warm should, with proper 
care, not be forgotten in bad cases. In local pelvic inflammations 
where the temperature runs above 102° F. we are in the habit of 
reducing it, as well as of relieving pain, by the steady application of 
large flat ice-bags or of the ice-water coil (a coil of rubber tubing 

Fig. 7. 




Ice-water Coil. 



through which ice-water is kept constantly flowing from an irrigator). 
A dangerous reduction of temperature is scarcely to be feared from 
these local applications of cold. In a very depressed condition of the 
general system great caution should, of course, be observed with these, 
as with all measures tending to depress the vital forces. 



MEANS OF DIAGNOSIS. 71 



CHAPTER V. 
DIAGNOSIS OF THE DISEASES OF THE FEMALE GENITAL ORGANS. 

The diagnosis of the diseases of the pelvic viscera of the female 
offers many obscurities, and frequently foils the most careful and capa- 
ble practitioners. With the utmost caution, assisted by the most prac- 
tised skill, no one can avoid occasional errors, while in the experience 
of those not possessing these qualifications they must be frequent and 
glaring. The only safeguard which can be established against their 
occurrence and the only guarantee which can be obtained for success 
in prognosis and treatment, is the thorough mastery of the subject which 
is now to engage us. 

It is not rare for one making a special study of gynecology to find 
those less familiar with it committing errors of diagnosis — or, what is 
more common, arriving at no conclusion — in cases which are perfectly 
simple and present no obscurities whatever. When meeting such 
instances in the practice of intelligent men we have been struck by 
the fact that the source of difficulty is almost always the same. The 
failure of diagnosis has not been due to their having drawn incorrect 
conclusions from diagnostic means, but to their not having brought 
these means fully into action and properly applied them to the solution 
of the case in hand. In many instances, uterine disease being sus- 
pected, the physician employs vaginal touch and follows it by the 
speculum. If the cervix be diseased, he is successful in diagnosis ; 
but if not he becomes discouraged, forgetful of the fact that rectal 
touch, the uterine probe, dilatation by tents, conjoined manipulation, 
and other means should be resorted to, and that without appealing to 
these even the most skilful diagnostician would be as helpless as him- 
self. There are means at our command for exploring every tissue 
within the pelvis — the uterus, the ovaries, the areolar tissue, etc. ; and 
until they are brought into service carefully, systematically, and thor- 
oughly no one can feel that he has done justice to his powers of dia- 
gnosis or allowed himself full opportunity for drawing correct conclu- 
sions. Skill in diagnosis must be obtained at the bedside, but for 
that school to be made profitable the student must have a thorough 
familiarity with the theory of the means of investigation which he is 
there to apply. Having mastered these, let him in an obscure case 
develop them one after the other, slowly, carefully, and thoughtfully, 
until he has arrived at a diagnosis, or at the fact that he is unable to 
make one even after having availed himself of all the resources at his 
command. 

Let us illustrate this by a supposititious case: An inexperienced 
examiner discovers upon vaginal touch that the vagina is occupied by 
a large tumor. If he rest satisfied with this method of exploration. 
and without reflection adopt the idea that the case is one of fibrous 



72 MEANS OF DIAGNOSIS. 

polypus, he may commit a grave error. The most skilful of gynecolo- 
gists could not decide by touch alone, and would be, almost as much 
as he, exposed to error if he relied upon it. All the means which the 
experienced diagnostician can bring to his aid are likewise at the ser- 
vice of the inexperienced ; and if the former stand in need of their 
assistance, surely the latter much more decidedly requires it. Let 
him then ask himself this question, although he may feel absolutely 
positive, altogether certain, that he is dealing with a fibrous polypus : 
What else may this be ? At once the answer will come, It may be 
a case of prolapsed uterus or of inversion of the uterus. It is import- 
ant that he should know which it is, and usually it is quite easy to 
decide. 

Drawing down the tumor, he examines by inspection and touch, 
and seeks the os externum, up which to pass the sound. It is not 
anywhere to be found, and moreover the tumor is larger below than it 
is above. The case is not one of prolapsus, and he feels that his dia- 
gnosis of polypus is surely correct. If it be a polypus which occupies 
the vagina, the uterus should be above it. He now practises conjoined 
manipulation, but to his surprise this organ is nowhere to be felt. This 
may be due to his want of experience, and he examines further with 
the sound, endeavoring to pass it alongside of the neck of the tumor 
and into the uterine cavity. He is surprised again to find that it is 
arrested at the neck of the tumor, around which he now passes his 
finger, and finds it closed everywhere by a gutter of circular character 
existing about an inch above the lips of the dilated os. The case now 
looks like one of inversion, but he is not sure, for sometimes adhesive 
inflammation attaches the walls of the cervix to the neck of the poly- 
pus. Are there any means by which he may settle this question posi- 
tively ? By conjoined manipulation he thinks that he feels a ring or 
circle over the abdominal face of the tumor, and gradually he pushes 
his fingers into it and becomes positive of its existence. 

Now, placing the patient upon the back, he passes one finger into 
the rectum and a sound into the bladder, and approximates them above 
the tumor. He finds no uterus intervening, and his diagnosis is made : 
the case is one of inversion of the uterus. This is his diagnosis ; that 
is, his deduction carefully and philosophically drawn from the premises 
presented to him by the best means at his disposal. Let him resort to 
all these means, and success will usually be his. But, it may be sug- 
gested, he is not as familiar with these means as a more experienced 
man is. Practically, we agree that he is not ; but why is he not theo- 
retically ? Are they not recorded and fully explained in all his works 
on gynecology ? What is demanded of him is not experience, not wis- 
dom, but a faithful and earnest effort to arrive at the truth by simply 
employing means which science places at his disposal. 

These remarks of course apply with equal force to every condition in 
which a diagnosis is required. Let it be a constant habit to demand 
of one's self, after admitting a suspicion as to the nature of the disease, 
What else could present the physical appearances which exist ? Hav- 
ing carefully considered this, let the various means of differentiation at 
command be fully tested. Then if an error of diagnosis creep in to 



RATIONAL SIGNS. 73 

damage interests entrusted to his charge, the mortified diagnostician 
may console himself with the reflection that at least he has exerted 
himself to the utmost of his ability to avoid it, and not fallen into a 
trap set for him by carelessness, indolence, or incompetency. 

It must not be forgotten, however, that certain rare and exceptional 
cases will occasionally occur, the diagnosis of which will baffle the skill 
and experience of the most cautious and conscientious. Take, for 
example, the following : l A patient aged sixty-two years had a movable 
abdominal tumor which was examined by a number of physicians. She 
died suddenly, and autopsy revealed extra-uterine pregnancy, a child 
weighing four and a half pounds lying loose in the peritoneal cavity. 
Or this : 2 A tumor is discovered in the pelvis ; the patient dies from 
some cause disconnected with it, and it is found to be a displaced kid- 
ney. 3 But such cases are rare. The careful and intelligent diagnos- 
tician will very generally be successful. 

Rational Signs. 

In the examination of a patient suspected of having uterine disor- 
der no direct or suggestive questions should be asked, but the symp- 
toms should be drawn forth by encouraging and properly directing her 
narrative of her case. Certain signs, which we call "rational" from 
their appealing to our reason and not to our senses, such as pain in the 
head, back, and limbs, menstrual disorder, leucorrhcea, impeded loco- 
motion, derangement of the digestion, and nervous manifestations, will 
lead us to suspect the genital organs, and may even convince us of the 
existence of disease there. Generally, however, they result in the 
adoption of other and more certain means of diagnosis, which are 
termed "physical." 

Every one will, after due experience, adopt some system by which 
his examination of patients will be expedited and the certainty of 
arriving at a correct diagnosis be increased. The plan which we con- 
sider best adapted to these ends is that which follows : 

1st. The personal history, age, etc. of the patient should be obtained. 

2d. The duration of the illness should be fixed. 

3d. The history of the attack from commencement to date should 
be elicited. 

4th. The present state of the patient should be ascertained. 

In obtaining the history of the disease no leading questions have 
thus far been asked ; the patient has told us what she herself has 
observed. Her evidence leads us to suspect some special disorder, 
and then we proceed thus : 

5th. Direct questions are put with the intent of testing the cor- 
rectness of the suspicion which the patient's story has excited. 

1 N. Y. Medical Record, Feb. 1, 1872, p. 539. 

2 Braitkwaite' s Retrospect, Part 37. 

3 I removed by laparotomy a tumor of the size of an orange situated behind and 
to the left of the uterus, as low down as the pelvic floor, which 1 took to be an enlarged 
and adherent ovary and tube, but which proved to be the left kidney, which I had 
peeled out of its capsule as neatly as it could have been done on the post-mortem table. 
Of course nothing remained but to remove it. The patient made a comparatively 
uneventful recovery. (See N. Y. Med. Journal, July 21, 1888.) — P. F. M. 



74 MEANS OF DIAGNOSIS. 

6th. Physical means are brought to the corroboration of the dia- 
gnosis by rational ones. 

Forms, either written or printed, such as that which follows, will 
not only save a vast deal of time and trouble, but give uniformity to 
histories taken, so that after a number of them have been accumulated 
they may be collated with reference to special points or preserved for 
personal reference or publication : 

Case, No Date, 

Name Age Married ? 

No. of children No. of abortions Time since last 

pregnancy Age at which menstruation appeared 

Duration of present illness Symptoms during its course 



Supposed cause 

Present condition as regards — 

/Regularity 
Amount — 
( Pain 

{Character.. 
Amount.^ 
Constancy 
Locality.- 



Pain. 

Degree 



Locomotion . 

Other symptoms 

f By touch 

Physical signs. ■< By speculum 

(_ By probe 

Other organs 

General health 

Diagnosis Prognosis- 
Treatment 

Result 



MANAGEMENT OF PATIENT DURING EXAMINATION. 75 

It will be observed that we have not enumerated the various rational 
signs generally attendant upon uterine affections, but merely the means 
for drawing them forth. Their special mention will be reserved for the 
study of particular affections. If the evidence elicited leaves any 
of the pelvic viscera under suspicion, this is verified or removed by 
means which are more positive and reliable from the fact that they 
address our senses. 

It will farther be seen that the headings of our table are not 
numerous, nor the table itself lengthy or exhaustive. Our belief is 
that the chief reason why such tables are not more generally employed 
is that they are so long and so filled with non-essential items as to 
become tedious and impracticable. This table is that which we employ 
in daily practice. We find that when filled out it gives all the salient 
points in our cases, and these are all that Ave desire ordinarily to 
preserve. 

Management of Patient during" the Physical Examination. 

Before commencing the consideration of physical signs, we shall 
make a few remarks upon a subject of great importance in this con- 
nection — namely, the management of the patient during the examina- 
tion. As Dr. Sims has taught us, she should never, unless it be 
impossible to do otherwise, be examined upon a bed or sofa, but upon 
a table covered with a blanket, shawl, or rug of some kind and pro- 
vided with a small pillow. The facility thus given for thorough investi- 
gation is very great, and the avoidance of the sinking of the body into 
the soft bed repays most fully the extra trouble which it causes to 
make the change. It may be said that many ladies will strongly 
object to the exposure incident to getting upon a table. This is not 
so: a little persuasion will overcome such objections at once, and the 
increased exposure is in reality imaginary, for the table is to all intents 
a bed, and a sheet for covering the person gives all desirable protection. 
Should it be necessary to employ a bed, the leaf of a dining-table or a 
wide board should be slipped across the mattress under the upper sheet 
and covering, and a hard surface will thus be presented for the patient 
to lie upon, which will obviate in great degree the objections to the 
bed otherwise arranged. 

The patient should always lie upon her back in a first examination, 
with the clothing loose around the waist, the knees drawn up, and the 
abdominal walls relaxed. A sheet should be spread over her so as to 
conceal the entire person. The table having been previously turned to 
a window admitting a strong light, a chair should be placed at its foot 
for the examiner, and at the right side of it another upon which has 
been arranged a basin of warm water, soap, and a towel. 

At the homes of patients, whenever a thorough digital examination 
of their pelvic organs is to be performed, we always place the patient 
crosswise on her bed, with nates close to the edge and knees elevated. 
Even patients suffering from acute pelvic inilammation or puerperal 
septicaemia can be placed in this position without much exertion or 
exposure; and it is only in this manner that a thorough and careful 



76 



MEANS OF DIAGNOSIS. 



bimanual examination can be made, unless we resort to the often inex- 
pedient, and perhaps hazardous, plan of putting the patient on the 
table just referred to. 

A variety of tables for these examinations in the physician's office 



Fig. S. 




Thomas's Gynecological Table. 

are now before the profession. We here present that which we employ 
both in office and hospital practice. For the cylindrical speculum it 
presents the advantages of an ordinary table ; for Sims's speculum, a 

Fig. 9. 




Thomas's Gynecological Table. 



great many more. Fig. 8 represents the table prepared for an examina- 
tion on the back ; a pillow supports the head, the buttocks are slightly 
elevated, and the feet rest upon the projecting pieces. When this 
examination is completed the patient stands upon the chair or stool 



ANAESTHESIA. 77 

recently occupied by the examiner, and the table is changed for 
examination with the speculum in Sims's position, as shown in Fig. 9. 
The top of the table is now elevated at one side, so that it slants 
decidedly to the other. The ankles of the patient, resting one upon 
the other, are supported by the projecting pad upon the end of the foot- 
piece. The other foot-piece has now been pushed into the body of the 
table. This position, by gravitation, throws forward the viscera, and 
thus aids in rendering the action of Sims's speculum more perfect. It 
will be observed that the slanting surface of the table is now supported 
by the hinged piece which in Fig. 8 lies as a flap along the side of the 
table, but in Fig. 9 is turned up. [I have modified this table, which 
I have used for many years, by gradually adding to it various drawers 
for the keeping of instruments, one of Avhich, at the left of the foot of 
the table, is also used as a step for the patient to mount. The lateral 
tip has not been used by me for some years, as I have found the cor- 
rect latero-abdominal position amply sufficient for specular examina- 
tion.— P. F. M.] 

Means of Physical Diagnosis. 

We shall enumerate and consider these in the order in which they 
will generally be employed in a case requiring the aid of all of them 
for its elucidation : 

1. Anaesthesia. 

2. Inspection. 

3. Vaginal touch. 

4. Conjoined manipulation. 

5. Abdominal palpation. 

6. Abdominal palpation conjoined with the use of the sound. 

7. Rectal touch. 

8. Vesico-rectal exploration. 

9. The speculum. 

10. The uterine probe and sound. 

11. The elastic sound. 

12. Tents. 

13. The dull curette. 

14. The exploring needle. 

15. The aspirator. 

16. The microscope. 

17. Auscultation and percussion. 

Anesthesia. — This should not be resorted to unless there be some 
special indication for it. Should the patient be intractable, delirious, 
or a malingerer, should the investigation involve much severe pain, or 
should there be some tonic spasm of the muscles as an element of the 
disease, as in the case of spurious pregnancy and phantom rumors, it 
affords an aid to diagnosis of great value and should never be neglect- 
ed. When we are forced to examine a virgin "who is very sensitive 
and opposed to the investigation, it is sometimes advisable, for without 
it a diagnosis is frequently impracticable. One even of large expe- 



78 MEANS OF DIAGNOSIS. 

rience is often greatly surprised by the results of two consecutive 
examinations, the one without and the other with anaesthesia. The 
second not only corrects the shortcomings of the first, but throws a 
flood of light where obscurity existed before. 

Inspection. — We invariably make a practice, before examining 
new patients, to expose the external genital organs under the sheet, 
and to examine them carefully for any possible pathological condi- 
tions. We may thus find enlargement of the labia majora, nymphae, 
or clitoris, or mucous patches, or pediculi pubis, of which no mention 
was made by the patient during the oral examination, or a lacerated 
perineum, a protrusion of the anterior or posterior vaginal wall, or 
hemorrhoids, or a urethral caruncle, — all of which we might possibly 
not have discovered if we had not inspected the external genital organs. 
If there is a suspicion of an abdominal tumor, inspection will reveal 
its shape, size, and certain irregularities in it which differ from the 
ordinary regular ovoid outline of a unilocular ovarian cyst or the 
pregnant uterus ; which irregularity probably stamps the tumor as a 
polycystic one. 

Vaginal Touch. — This, which will be the first explorative mea- 
sure to which the examiner will resort, constitutes one of the most 
important at his command. It will reveal much or little as it is prac- 
tised slowly and thoughtfully, or hastily and as a matter of routine. 
In making it, the index finger of either hand may be employed, and 
when it is desirable to reach as far up the pelvis as possible the index 
and middle fingers may be used. During this examination the patient 
should invariably be laid upon the back, with the legs flexed and the 
buttocks very near the edge of the table. The observance of this 
position is of great importance, as vaginal touch should in every case 
be combined with abdominal palpation, to which union the name of 
conjoined manipulation or bimanual palpation has been applied. 
Too much stress cannot be laid on the invariable observance of this 
rule. 

The index finger of one hand, being introduced into the vagina, 

O . 7 o o ' 

the other fingers being flexed into the palm and the thumb laid upon 
them, passes directly to the cervix uteri, assuring the investigator as 
it goes of the perviousness of the vaginal canal. Upon reaching the 
os, this part is carefully examined with reference to size, consistency 
of lips, and character of discharge, a patulous os, with soft, velvety 
sides covered by a glutinous secretion, admonishing him of the exist- 
ence of inflammation of the os and cervical canal. The cervix should 
then be examined with reference to location, size, and density. This 
being done, the finger should be slid along its posterior surface into 
the recto-uterine space, and the presence of any hardness or tumefac- 
tion there be noted. Should such be found, it will probably be due 
to one of these causes : retroflexion or retroversion of the uterus, 
uterine enlargement, a fibrous tumor, scybalse in the rectum, inflam- 
matory products the result of peri-uterine cellulitis or peritonitis, a 
prolapsed ovary or ovarian tumor, or a hematocele. Should no tumor 



CONJOINED MANIPULATION. 79 

be discovered, but the line of resistance given to the finger be found 
to disappear at the vaginal junction with the uterus, it may be 
inferred with moderate certainty that at this point none of the above- 
mentioned conditions exist. The finger will also ascertain whether 
the normal mobility of the uterus is present by attempting to move 
the organ in various directions through pressure on the cervix. The 
absence of such mobility would denote the pre-existence of pelvic 
inflammation and the presence of pelvic adhesions. 

This space being explored, the finger should then be passed ante- 
riorly, and swept upward and forward along the base of the bladder 
toward the symphysis pubis. Any hardness discovered here will prob- 
ably be due to anteflexion or anteversion of the uterus, a fibrous tumor, 
stone in the bladder, uterine enlargement, or possibly cellulitis. 

The state of the ovaries should then be tested by lateral pressure, 
and the condition of the pelvic areolar tissue and walls be ascertained 
by firm pressure in all directions. 

In certain rare and obscure cases — such, for example, as those in 
which a diagnosis of large tumors in the vagina is very difficult — it 
becomes necessary to introduce the whole hand into the vagina. This 
procedure, which should be resorted to wmile the patient is anaesthe- 
tized, must be practised with the greatest caution. Otherwise injury 
may be done to the parts about the vulva, and a large and carelessly 
managed hand may produce rupture of the vagina. 

One manoeuvre, by which touch of the parts lying closely in con- 
tact with Douglas's cul-de-sac is much facilitated, still remains to be 
mentioned. Where small tumors exist behind and disconnected with 
the uterus, or where enlarged and prolapsed ovaries are to be sought 
for and examined, an excellent result is often obtained by placing the 
patient in Sims's left lateral position, and passing the index and middle 
fingers of the right hand as high up as possible, their palmar surfaces 
looking toward the posterior wall of the vagina. By this method we 
have repeatedly detected enlarged and slightly displaced ovaries which 
in the dorsal decubitus had entirely escaped observation. 

Conjoined Manipulation, or Bimanual Palpation. — As the 
preceding examination consists in touching organs above the pelvic 
roof for the most part, and which are generally quite movable, it is 
evident that its results are diminished by ascent of these parts as thev 
are pressed upon. To bring them more fully within the reach of the 
finger in the vagina, and to prevent their retreat, abdominal palpation 
should invariably be combined with vaginal touch. While the latter is 
being performed by the index finger of one hand, the other hand should 
be placed on the abdomen, and by it the uterus be made to descend, so 
that even its upper parts may become accessible. This will enable the 
examiner to sweep the finger in the vagina over the posterior, anterior. 
and lateral surfaces of the organ, and detect the presence of any enlarge- 
ment, sensitiveness, or abnormal growth there. Fig. 10 represents this. 

But not only should the walls of the uterus be thus explored : the 
volume, shape, sensitiveness, and regularity of surface of this organ, as 
well as of the ovaries, the broad ligaments, anterior vaginal wall, ami 



80 



MEANS OF DIAGNOSIS. 



bladder, should likewise be ascertained. To accomplish this with ref- 
erence to the uterus, let the finger in the vagina be placed under it — 
anterior to the cervix if it be in normal position or anteflexed, posterior 
to it if it be retroflexed — and the organ will be distinctly felt resting 

Fig. 10. 




Practice of Conjoined Manipulation. 

between it and the fingers which depress the abdominal wall. By the 
same method the other parts mentioned should be examined. Con- 
joined manipulation is of great importance; indeed, no examination 
can be considered complete without it. By a neglect of this seemingly 
trifling precaution we have known the existence of large tumors, and 
even of pregnancy quite advanced, entirely ignored. Some time ago 
a physician sent to us from a distance a case which he supposed to 
be one of prolapsus uteri, from the fact that the uterus was low in the 
pelvis, never suspecting for a moment the existence of two fibrous 
tumors, each the size of a foetal head, which depressed the displaced 
organ. 

Were we called upon to mention the most important method of dia- 
gnosis at the disposal of the gynecologist, not excepting the speculum 
and sound, or even the two of them together, we should unhesitatingly 
select conjoined manipulation. Until recently it was less generally 
known, and much less generally appreciated, than it deserves to be. 

Not only may this method be practised by combination of vaginal 
touch with abdominal palpation : it may likewise consist of the com- 
bination of the latter with rectal touch by one finger, or by the in- 
troduction of the forefinger into the bladder, after dilatation of the 
urethra. 



Abdominal Palpation. — The practice of bimanual palpation will 



ABDOMINAL PALPATION. 81 

have assured the investigator of the presence of any tumors which may 
exist in the pelvis. Should such have been discovered, a further examina- 
tion will of course at once be entered upon to ascertain their size, shape, 
attachments, and contents. In this exploration both hands are employed 
externally, and by them firm pressure is made and the abdominal walls 
depressed, so that by grasping the masses their characters may be appre- 
ciated. By this means the diagnostician decides as to the solidity or 
fluidity of tumors, their sensitiveness to pressure, the presence of foetal 
movements, and other points of equal importance. 

Abdominal Palpation conjoined with the Use of the 
Sound. — We shall very soon speak of the uterine sound in relation 
to its ordinary and more legitimate functions. Here we allude to it 
only as a means of rotating the uterus in the pelvis in order that the 
hand pressed upon the abdomen may separate it from enlargements in 
the abdomen. This method of investigation is of so great value, and 
appears to us so little appreciated and so rarely practised, that we 
wish to draw especial attention to it. Let us suppose that a tumor 
occupies the pelvis or lower portion of the abdomen, and it be desired 
to determine how close a relation exists between it and the uterus. 
The sound being passed to the fundus, the patient lying upon the back, 
it is made to rotate the uterus. The left hand, which is unoccupied, 
is now placed on the abdomen, so as to become cognizant of movements 
in the uterus and tumor. If both move equally, their connection is 
intimate ; if the uterus move freely and the tumor but little, it is less 
marked ; while if the tumor remains stationary during rotation of the 
uterus, there is probably no connection or one only by lengthy bonds of 
union. 

Again, in cases where palpation and conjoined manipulation fail 
to map out the position of the uterus on account of obscure pelvic 
tumors or great obesity of the woman, lifting the organ by the sound 
and rotating it under the palm laid upon the abdomen is a valuable 
resource. 

Lastly, in cases of supposed fibrous polypus, where one fears to 
operate lest an inverted uterus may have misled him, although the pas- 
sage of the sound alone makes him almost sure as to diagnosis, it gives 
confidence to feel the uterine body rolling under the hand laid over the 
abdomen, for it is not an unheard-of occurrence for the sound to pass 
through the uterine walls and enter the peritoneum. 

We would urge this procedure, as a rule, in the examination of 
abdominal and pelvic tumors. Indeed, in a large number of such cases 
a neglect of it will allow of errors in diagnosis which by its adoption 
might have been avoided. 

The method of exploring pelvic viscera of the female by moans of 
the whole hand introduced into the rectum, first practised and recom- 
mended by the late Prof. Simon of Heidelberg, has now fallen into 
general disuse, for the reason that rupture of the intestine was produced 
in a number of cases with fatal results, and that with our present 
improved methods of diagnosis, and the practice daily growing more 
popular of deciding the exact nature and complications of a pelvic or 
r> 



82 



MEANS OF DIAGNOSIS. 



abdominal tumor by the fingers, introduced through an abdominal 
incision, the necessity for a rectal exploration of such severity is 
entirely done away with. 

A great deal more can be accomplished by the introduction of the 
hand except the thumb into the rectum, after stretching the sphincter 
ani, than by the old method of introducing only one or two fingers. 

Should any substance lie in the recto-vaginal space, its character 
may be accurately appreciated by what has been styled by Dr. Tilt the 
" double touch," which consists in introducing the index finger into the 
rectum and the thumb into the vagina, and then approximating them. 
Or the index of one hand may be introduced into the vagina and that 
of the other into the rectum. 



Digital Eversion of the Rectum. — The lower portion of the 
rectum may be very easily exposed, although this manipulation is 
attended with some pain, by inserting two fingers into the vagina and 
everting the part of the rectum thus controlled through the anus. The 
diagnosis of internal hemorrhoids, fissure, catarrh, and ulceration of 
the lower part of the bowel is thus very readily made. 

Fig 11. 




Digital Eversion of the Rectum. 



Vesico-rectal Exploration. — This consists ordinarily in passing 
a catheter or sound into the bladder and pressing it toward the index 
finger in the rectum. Its scope is not extensive, but for some pur- 
poses no other method answers the same end, as, for example, for the 
following : 

Appreciating the size of the uterus in very fat women ; 
Detecting absence of the uterus : 
Differentiating inversion from polypus. 
The only difference between this method and conjoined manipulation 
consists in the attempt to grasp the uterus between the finger and sound 
instead of between the fingers of the two hands. 

This method may be practised in still another manner — that pro- 
posed by Noeggerath. It consists in dilatation of the urethra by 



THE SPECULUM. 83 

graduated dilators, the introduction of the index finger of one hand 
into the bladder and that of the other into the rectum or vagina, and 
the approximation of these, so that the uterine walls, anterior, posterior, 
and lateral, can be carefully and thoroughly examined. This method, 
like that of Simon, should be resorted to only in obscure and difficult 
cases not susceptible of elucidation by other means. 

The Speculum. — This is by no means our most valuable diagnostic 
resource. Too great a reliance upon it as such is calculated to dimin- 
ish the physician's powers for arriving at a correct conclusion in obscure 
cases. Unquestionably, the greatest benefits derived from the speculum 
demonstrate themselves in the therapeutic department of this subject. 
As a diagnostic means it is inferior to vaginal and rectal touch com- 
bined with abdominal palpation, and chiefly aids us in this field by 
opening the way to the proper use of the uterine probe, which consti- 
tutes one of the most reliable methods at our command for appreciating 
the condition of the cavity of the uterus. Let any one who is sur- 
prised at the statement — which many will be — reflect as to what can 
really be seen even in aggravated cases of disease, except malignant, 
granular, and cystic degeneration of the cervix. The position of the 
uterus, its mobility, the presence of a foreign body in its cavity, the 
condition of its surrounding tissues, can none of them be learned from 
the sense of sight. 

All vaginal specula may be classified under two heads — cylindrical 
and valvular. Of the first variety, cylinders of metal, porcelain, ivory, 
and wood are in general use. None of these compare in elegance, 
cleanliness, and utility with that of Dr. Fergusson of London, which 
consists of a tube of glass coated with quicksilver and covered by India- 
rubber, which is thoroughly varnished. This instrument is represented 
in Fig. 12. 

Fig. 12. 




Fergusson's Speculum. 

As a rule, cylindrical specula are made too long ; they should not 
be longer than from four to five inches, and should come in sets of at 
least four, measuring from one to two and a half inches in diameter. 
The antiquated instruments of Cusco, Ricord, Se'gallas, and Charrifcre, 
with their numerous modifications, all constructed on the principle of 
a closed flattened metal tube, which, after introduction into the vagina, 
is opened and expanded by means of a screw in the handle, are no 
longer employed by the progressive gynecologist. The general practi- 
tioner will, however, still find himself compelled, in the absence of an 
office nurse, to use either the cylindrical or one of the improved forms 



84 



MEANS OF DIAGNOSIS. 



of valvular specula ; and for his benefit we mention the instruments 
of Brewer and Nott as the best instances of the bivalve and trivalve 
varieties respectively. 



Fig. 13. 




Brewer's Bivalve Speculum. 



Fig. 14. 




Xott's Trivalve Speculum, closed. 



A peculiar, double shoehorn-shaped speculum has been devised by 
the late Prof. Neugebauer of Warsaw, which has found favor in the eyes 
of Barnes, Chadwick, and a few other gynecologists. We, personally, 
have never felt the need of it. 

All valvular specula, however, present these great disadvantages : It 
is difficult to avoid prolapse of the vaginal wall between their branches, 
and in removing the instrument these are liable to be painfully pinched. 
If upon introducing and expanding their branches the os uteri is exposed, 
all goes well ; but if it is not in the field, these instruments are awkward 
and unwieldy in overcoming the difficulty ; indeed, in many cases the 
speculum must be withdrawn and reintroduced to accomplish the result. 
In virgins both cylindrical and valvular specula are usually impracti- 
cable without serious damage to the hymen and great pain ; only the 



THE SPECULUM. 



85 



Fig. 15. 



very smallest size of a cylindrical speculum may be inserted through 
the orifice of an elastic hymen, usually with the result of admitting so 
little light as to render its employment useless. In a married but nul- 
liparous woman, and above all in a multipara, both forms of specula 
can usually be employed without difficulty or pain. 

Like the cylindrical, valvular specula in general use do not, as a 
rule, admit of probing the uterus and making applications to the fun- 
dus. We do not deny that in some cases it 
is possible, nor that by perseverance a skilful 
operator may succeed in effecting these objects 
in many instances, but it is usually so difficult 
that the general practitioner will not find such 
specula available for these ends. 

Sims's speculum, Fig. 15, which is in real- 
ity a bivalve, obviates all these difficulties in 
the most complete and satisfactory manner. 
In exposing the uterus it develops a principle 
not brought into action by any other variety 
— the dilatation of the vaginal canal by air, 
which enters on account of the position of 
the patient and gravitation of the pelvic and 
abdominal viscera. We have stated that this 
instrument is a bivalve speculum : the upper 
valve is constituted by the blade of the spec- 
ulum itself, and the lower by the depressor, 
represented in Fig. 16, which acts upon the 
anterior wall. 




Sims's Speculum. 



Fig. 1 




Sims's Depressor. 



The facility which Sims's instrument gives for exploration and treat- 
ment is very great — so great, we think, that the practitioner devoting 



Fig. 1' 



r 



Sims's Tenaculum. 



himself to gynecology who does not avail himself of it loses a much 
greater advantage than the auscultator would forego in not bringing to 



86 MEANS OF DIAGNOSIS. 

his aid the double stethoscope of Camman. But, unfortunately, for a 
time this instrument presented such disadvantages that it could not come 
into general use. In the hands of those attending a sufficient number 
of cases of uterine disease to give them skill in manipulation and oppor- 
tunity for thoroughly familiarizing themselves with it, it always filled a 
large place, but in general practice it has been slow in becoming pop- 
ular. It cannot well be emplo} r ed without an assistant, and this assist- 
ant requires a certain amount of training to enable him or her to hold 
the instrument intelligently and without fatigue. But this training is 
easily acquired, and it is now rarely difficult to find a nurse or some 
female friend ready and able to help us in case we should unexpectedly 
need her assistance. Still, the fact that any assistant is needed has 
incited many to alter Dr. Sims's original model so as to combine its 
advantages in instruments free from the objections which have been 
mentioned. 

"When the posterior vaginal wall is lifted by Sims' s speculum, the 
anterior must be depressed by an instrument held in the other hand. 
Thus both hands are occupied and the operator is bereft of power to 
proceed. The object of the alteration is to liberate one hand in order 
that the further steps of the examination may be proceeded with. 

Fig. 18. 




Munde's Flange Sims's Speculum. 

Drs. T. A. Emmet, T. G. Thomas, the late Dr. J. B. Hunter, A. F. 
Erich, and W. L. Studley have all invented very serviceable, but unfor- 
tunately too complicated, instruments designed to enable the operator 
to dispense with an assistant. So far as we know, they have not met 
with popular favor. A comparatively trifling modification, merely 
designed to support the superior buttock, so as to prevent its obstruct- 
ing the view into the vagina, has been devised by Munde', who has 
used it exclusively for the last seven or eight years. This instrument, 
with a depressor to match, has recently been constructed of aluminium 
by George Tiemann & Co., and both are specially noticeable through 
their extreme lightness and incorrodibility by all chemical agents except 
a strong solution of bichloride of mercury. 

The best self-retaining Sims's speculum which we have seen is 
that invented by Dr. Clement Cleveland of this city. The retracting 
force in this instrument is exerted by a broad band, with a buckle, 
passed over the shoulders of the patient, the fulcrum being the latter's 
sacrum. 



THE SPECULUM. 87 

Method of Introducing Valvular and Cylindrical Specula. — The 
patient being placed in position on the back, as already explained, 
and the speculum, probe, and whatever other instruments are to be 
employed laid in a basin of warm water at the bedside, the physician 
seats himself in a chair, or, if a low bed be used instead of a table, 
kneels or sits upon a stool. The finger, having been thoroughly lubri- 

Fig. 19. 




Cleveland's Self-retaining Sims's Speculum. 

cated with soap or carbolized vaseline, is passed up and the location 
of the cervix ascertained. The speculum, similarly lubricated, is then 
passed in this way : If the cylindrical instrument be used, the peri- 
neum is depressed by its tip, and it is very slowly and gently inserted 
and carried to the cervix ; should one of the valvular varieties be 
employed, it is inserted closed and expanded after reaching the 
cervix. Both these specula may be used in the lateral (Sims's) position 
with equal facility. 

Introduction of Sims's Speculum and its Varieties. — In this 
method of examination the element which commands success is not 
the use of the instrument, but the position of the patient. If the 
position recommended by Sims be attained, exposure of the cervix 
will be easy ; if a similar but not identical attitude be substituted, the 
examination will prove entirely unsatisfactory. 

The object of the position is to allow the abdominal viscera 
to gravitate, so as to draw the anterior Avail of the vagina forward 
in a direction opposite to that impressed upon the posterior wall by 
the speculum. To accomplish this the patient must not be on her 
back nor on her side, but in a position between the two. This is well 
represented in Fig. 20. The left arm must be drawn behind the 
patient, so as to let her rest on the left side of the chest, and the 
right leg be so flexed as to let the right knee lie just above the left. 

When the patient is arranged the correctness of the posture may be 
tested by noting that the lower trochanter is not just opposite the 



88 MEANS OF DIAGNOSIS. 

upper, but nearer to the examiner by two or three inches. We are 
thus particular in describing this position — first, because it is difficult 
for one not accustomed to its employment to place his patient properly 
in it ; and, second, because upon its perfect attainment depends the suc- 
cessful use of Sims's speculum. The patient being in position, the 

Fig. 20. 




Position of Patient, Physician, and Nurse during an Examination with Sims's Speculum. 

speculum is introduced, the posterior vaginal wall elevated by it, and 
the anterior depressed by the depressor, Fig. 16, held in the other 
hand. 

One reason why the great advantages of Sims's speculum were for a 
time not more generally recognized and acknowledged was unquestion- 
ably to be found in the fact that the patient was not properly arranged 
before its introduction. To impress this fact, and to show how faulty 
the arrangement of the patient may be, we introduce a diagram from a 



THE SPECULUM. 



89 



very excellent French work upon gynecological surgery. No diagram 
could better represent how the woman should not be placed than 
this. 

Fig. 21. 




Incorrect Representation of Position of Woman in Examining with Sims's Speculum 

(Leblond). 

A series of vaginal depressors and elevators, to be used solely in 
the lithotomy position was devised by the late Prof. Simon of Heidel- 

Fig. 22. 




Simon's Specula: Blades of various sizes and shapes. 

berg, mainly for use in operations on the vagina and cervix : through 



90 



MEANS OF DIAGNOSIS. 



them he achieved his, at that time, marvellous results in curing vesico- 
vaginal fistulse, prolapsus uteri, and lacerated cervices. Edebohls of 
New York has devised a modification of these instruments. Fritsch 
of Breslau has also constructed a very ingenious contrivance for sup- 
porting and steadying the legs of the patient and retaining the mod- 
ified Simon's specula, but it is obvious that such complicated contri- 
vances are not needed when one competent assistant can be procured 

Fig. 23. 




Simon's Position for Vesico-vaginal Fistula Operation (Simon). 

to hold the Sims' s speculum. We have found that, as a rule, wher- 
ever such operations are to be performed, sufficient assistance can 
readily be obtained free of expense, and trained gynecologists are by 
no means essential to hold a speculum or wash a sponge. 

The Uterine Sound. — This valuable diagnostic means, although 
to a certain extent known in ancient times, was more recently recom- 
mended in 1828 by Samuel Lair. 1 It was not, however, adopted upon 
his recommendation, and it was not until about the year 1843 that 
it was generally accepted. At this time its claims were simultaneously 
urged by Simpson of Edinburgh, Huguier of Paris, and Kiwisch of 
Prague, working without concert. It matters little to which of them 
belongs the credit of having been the first to conceive the idea of the 
regeneration ; to Simpson certainly belongs that of having forced it 
upon the attention of the profession and established its value by clinical 
evidence. 

1 Samuel Lair, Nouvelle Methode de Traitement des Ulceres, Ulcerations, et Engorge- 
ment de V Uterus, 1828. 



THE UTERINE SOUND. 91 

The instruments in general use are those of Simpson and Sims, 
which differ from each other in principle, the Simpson consisting of 
a stiff metal rod divided into quarter inches, flexible by pressure before 
its introduction ; and the Sims, a flexible silver-plated staff, thinner than 
the other. Practically, at present, the Simpson sound only is in use. The 
method of their introduction is : The index finger of one hand being 
introduced into the vagina and placed against the cervix, the sound is 
by the other slid upon its palmar surface to the os, passed into it, and 
by depression of the handle gently advanced to the fundus. If the 
uterus be in its normal position and the sound be used by a skilful hand, 
the operation is not difficult. But it is not the healthy uterus which 
we are generally called upon to explore. If the organ be displaced, the 
difficulties and dangers attending the employment of the sound are 
considerable. 

Precautions and Dangers. — In introducing the sound it is essen- 
tial, above all, that no force whatever be used, and that, particularly 
when the point of the sound has passed the internal os, care be taken 
that it touch the fundus very gently, otherwise it might, in cases of 
flabby uteri, very easily pass through the fundus and enter the perito- 
neal cavity. This accident has occurred so frequently — indeed, we 
ourselves have within the last few years seen it happen in our hands 
under most gentle management in four cases, fortunately with no bad 
results (P. F. M.) — that we deem it proper to caution all beginners 
against this possible danger. Besides, the sound if roughly used may 
cause more or less severe hemorrhage from the uterus, and it has been 
known to set up a pelvic peritonitis. It is self-evident that, as with 
all other instruments used in gynecological examinations, the sound 
should be carefully cleaned and warmed in an aseptic solution before 
being; introduced. Of course care should be taken never to insert the 
sound into a uterus which, from the history of the patient, may possibly 
contain a product of conception ; that is, never to use the sound when 
the patient admits that she has missed one or more menstrual periods ; 
nor should the sound be used if there is any record of pelvic inflamma- 
tion, recent or remote, unless all traces have been found absent on a 
careful examination ; and never under any circumstances to introduce 
the sound into the uterus until a thorough bimanual examination of 
the uterus and the other pelvic contents has demonstrated the absence 
of any contraindication to the instrument. The routine use of the 
sound is certainly to be condemned, but with a careful observance of 
the above precautions we do not think that it will often do harm : and 
we have made it a rule in our practice for many years, when examining 
a patient for the first time, to assure ourselves of the exact condition 
of the endometrium by inserting the sound carefully and gently when- 
ever the contraindications above mentioned were absent. We feel that 
the information thus obtained has by far outweighed the very rare 
injuries inflicted. We usually prefer to introduce the sound on the 
finger by touch only, as prescribed, instead of through the speculum, 
because the finger enables us more accurately to gauge the resistance 
offered to its passage and the direction in which to introduce it. Occa- 



92 



MEANS OF DIAGNOSIS. 



sionally, however, finding this difficult, we are forced to introduce it 
through the Sims speculum. To pass a sound through a cylindrical or 
bivalve speculum is usually unsatisfactory, and perhaps even dangerous. 
The facts which may be ascertained by the sound are these : 

1. The capacity of the uterus ; 

2. The existence of growths within it ; 

3. Deviations of the course of its canal ; 

4. Differentiation of displacements from uterine tumors ; 

5. The mobility of the uterus. 

The great importance of these facts with reference to diagnosis is 
evident, and one would suppose that an instrument revealing so much 
would be universally employed. Such, however, is not by any means 
the case. Expert gynecologists can usually dispense with the sound, 
although at times it serves a purpose which is unattainable by any 
other means, and makes a difficult diagnosis easy. But to cast it 



pernicious, 



and 



unnecessary, as is 



being 



aside entirely as useless, 

done at present by some eminent authorities, seems to us unwise 
and uncalled for. The indiscriminate use of the sound by inex- 
perienced hands should, however, certainly be condemned. 

The Sims flexible sound has 
fallen into disuse because it was 
found that it could but rarely 
be used without the speculum, 
bending as it did too easily on 
encountering any obstacle. In 
place of it Sims devised a thin, 
excessively flexible probe of 
pure silver, which is used only 
through the Sims speculum in 
the following manner : 

Mode of Probing the Ute- 
rus. — While the woman lies on 
her back, the examiner, by 
vaginal touch, carefully ascer- 
tains the position of the uterus 
by passing his finger first into 
the fornix vaginae over its pos- 
terior face, and then along the 
base of the bladder, over its 
anterior wall. This gives him 
a definite idea of the direction 
of the canal along which he is 
to pass his probe, and without 
it he should never essay the 
procedure. The speculum is 
then introduced, the patient 
being turned on the left side. 
The examiner then takes the 
the exact curve which he sup- 




Sounds of Simpson and Sims compared 

probe, and with his fingers 



it 



poses the uterine canal to have, and gently endeavors to pass it m. 



TENTS. 93 

Should he fail, he withdraws the instrument, alters the curve 
slightly, and makes other attempts until he succeeds, which 
will be very soon if he has used this method so often as to have 
given himself experience. Every effort at introduction is made as 
cautiously as if the probe were passing into the larynx instead of the 
womb, and no force whatever is exerted. Success is attained by prop- 
erly curving the probe, and by that alone. Sometimes the inflection 
given to it must be the arc of a small circle, at others a sharp angle ; 
sometimes the instrument is left perfectly straight ; in fact, every vari- 
ety of direction may be given it. In a certain set of rare cases even 
a spiral twist is required. 

Thus employed, the uterine probe becomes a means of verifying a 
diagnosis which has been made by touch, and is certainly safe, easy of 
introduction, and painless. It may be used in all cases except preg- 
nancy, doing no injury even in endometritis, so gentle is its entrance 
into the inflamed cavity. 

No one can dispute the fact that having been passed it performs 
the chief functions of the sound, proclaiming the course, length, and 
capacity of the uterine canal. 

As the practitioner grows in skill in the practice of conjoined manip- 
ulation, that most valuable and reliable of all his means of diagnosis, 
he will less and less frequently find a resort to the sound or probe 
necessary. In the vast majority of his cases he will by that means so 
clearly determine all that the sound or probe could reveal that he will 
feel satisfied without further investigation. 

Some cases of enlarged uteri, with or without the presence of sub- 
mucous fibroids, require the use of an elastic sound for their full explo- 
ration. For this purpose sounds of gum elastic and whalebone have 
been employed. 

Tents. — Before the time of Recamier, the cavity of the uterus was 
a space entirely closed to investigation and local therapeutics, unless the 
os were greatly dilated by disease. He, however, not only aspired to 
an accurate knowledge of its affections, but boldly applied his remedies 
directly to the diseased surface, and in cases of intra-uterine granula- 
tions scraped off the diseased mucous coat with the curette. Even to 
him, however, the diagnosis of diseases within the cavity when the os 
was closed was an impossibility, and for the means of combating this 
difficulty we are again indebted to Dr. Simpson, who in 1844 placed 
the use of sponge tents among the most important of our resources for 
diagnosis. 

The object for which they are employed is the dilatation of the cer- 
vical canal, in order that the cavity of the body may be examined by 
touch or sight, and that treatment may be applied in eases of polypi. 
granulations, fibrous tumors, hydatids, removal of the products of 
conception, etc. 

Various substances have been recommended for the manufacture o( 
tents, only three of which have thus far come into general use — com- 
pressed sponge, laminaria digitata, or sea-tangle, and tupelo, or the 
compressed root of the Nyssa aquatica. 



94 



MEANS OF DIAGNOSIS. 



All these tents are now prepared at wholesale by manufacturers. 
No practitioner would think of making them himself, or need do so, 
no matter where he lives. They may be medicated with iodine, zinc, 
copper, or other substance, but are at present used almost exclu- 
sively to dilate the uterine canal, such local medication as may be 
deemed necessary being applied after their removal. A cord is passed 
through the outer end of the tent in order to facilitate its removal. 

Fig. 25. 




A Sponge Tent, with thread passing through it. 1 

Preparation of Sea-tangle Tents. — In 1862, 2 Dr. Sloan of Ayr, 
Scotland, first recommended the use of this substance for dilating the 
cervix uteri. The laminaria is an aquatic plant found upon various 
parts of the Atlantic coast of Europe and America. That found in 
the Bay of Fundy is far superior to any other in the market. This 
plant, when saturated with moisture, swells to three times the bulk 
which it has when thoroughly dried. In its moist state a long piece 
of it is perforated at both extremities, in order that it may be hung 
up and allowed to dry, a weight being attached to the lower end, so as 
to stretch it and make it straight. When dry, this is cut into pieces 
from two to two and a half inches long, and made perfectly smooth and 
round by a lathe or knife, a piece of glass, or sandpaper. 

Dr. Greenhalgh of London has improved these tents by having 
them perforated from one extremity to the other, so as to make them 

tubular instead of solid. Thus 
Fig. 26. prepared they will dilate much 

more rapidly and completely. 
One of Dr. Greenhalgh's tents 
is represented in Fig. 26. 

The advantages of these 
tents over those made of sponge 
consist in their creating no fetor 
and presenting no animal mat- 
ter for absorption. Their disadvantages are their requiring a longer 
time for expansion, their being kept in the cervix with greater diffi- 
culty, and offering a harder substance to the walls of the cavity of the 
uterus. 

The Tupelo Tent. — About fifteen years ago Dr. George E. Suss- 

1 The extremities of this thread should of course be tied together. 

2 Glasgow Med. Journ., Oct., 1862. 




A Sea-tangle Tent. 



TENTS. 



95 



dorff of this city introduced to the notice of the profession a tent made 
of the wood of the tupelo tree, or Nyssa aquatica, growing throughout 
the swamps of the Southern States ; the natural root was compressed 
by machinery and then smoothed and polished. It has the advantage 
over laminaria in coming in sizes varying between that of a knitting- 
needle and that of the middle finger. It expands more rapidly, 
equally thoroughly, more uniformly, with less constriction at the most 
difficult point of dilatation, the internal os, and coming in so much 
larger sizes than the laminaria can of course produce more thorough 
dilatation. It can be rendered equally aseptic with the laminaria, 
and, what is a great advantage, can be easily whittled into the proper 
size and length, whereas the hardness of the laminaria may resist even 
the sharpest pocket-knife. 

Comparative Advantages of the Sponge, Laminaria, and Tupelo 
Tents. — Sponge tents, formerly almost universally used, are now but 
very little heard of, having been almost completely supplanted by the 
tupelo, which latter is not only much more easy of introduction and 
much less liable to become offensive and produce peritonitis or septi- 
caemia, but expands with almost equal rapidity and thoroughness ; 
besides, the tupelo is more easily removed, and does not bring away 
with it a large portion of the uterine mucous membrane. The lami- 
naria tent, being seldom found larger than a small-sized lead pencil, 
cannot of course bring about the same amount of dilatation as the 
larger tupelo. It is true, a number of laminaria tents can be intro- 



Fig. 27. 




A Tupelo Tent, before and after Introduction and Expansion. 



duced side by side at the same time, and will then secure a very effi- 
cient dilatation, but it is not always easy to introduce several tents at 
once through a narrow uterine canal, and their habit of becoming 



96 MEANS OF DIAGNOSIS. 

twisted and contorted on expansion, and of being much constricted at 
the internal os, renders their removal often exceedingly difficult. 

Fig. 27 represents one of these tents before introduction in a case 
of a patient suffering from a submucous fibroid, and the same upon 
removal at the end of twenty-four hours. The figures are of natu- 
ral size. 

Mode of Introducing Tents. — A tent is best introduced through a 
speculum, preferably the Sims. Before the introduction of the tent 
the vagina should be syringed out with carbolized water, or. better. 
mopped out with a 1 : 10,000 solution of bichloride, and the tent, 
having been lubricated with carbolized vaseline and grasped by a 
pair of forceps, is directed in coincidence with the uterine axis, as 
ascertained by the probe, and gently pushed through the cervix. 

After this the vagina should be again cleansed as before, a mass of 
carbolized cotton packed against the cervix, so as to exclude atmo- 
spheric air and keep the tent in place, and the woman be directed to 
remain in bed until it is removed. 

Its withdrawal is accomplished through the speculum, after removal 
of the cotton and syringing with carbolized or bichloride water, in 
from twelve to twenty-four hours, with the same forceps by which it 
was introduced or by traction upon the thread attached to it. 

Dangers. — There is always danger in dilating the cervix by tents, 
though it is by no means so great as to make one hesitate in employ- 
ing them, for the cases which demand them are often urgent ones, and 
they serve a purpose not attainable by any other means. It is much 
to be regretted that practitioners have not shown more alacrity in pub- 
lishing unfortunate results from the use of this method of exploration 
and treatment. Had all the fatal cases which have resulted from acci- 
dents due to tents been faithfully recorded, the list would now be a long 
one. and it would be greatly lengthened by a record of all the instances 
in which tedious, exhausting, and dangerous disease has thus been 
excited. It may then be asked whether it is right to recommend a 
method accompanied by so much danger. The same line of argument 
applies to this question which does to so many similar ones in medi- 
cine. Great dangers attend the use of anaesthetics, of narcotics, and 
of other means which are in daily use. but the proportion of accidents 
occurring from their use is small, although the aggregate is large, and 
the good which they effect is so great that their evils must be con- 
doned. 

[In my own practice I have met with four fatal cases resulting from the 
use of tents. In one they were employed to remove a foetal shell which had 
been retained for two months and was destroying the patient's life by septi- 
caemia ; in the others the cervix was being dilated for the removal of fibrous 
polvpi, the hemorrhage from which had greatly exhausted the patients. 
One of these women died from tetanus, one from peritonitis, one from an 
overwhelming and sudden attack of septicaemia, and one from sloughing of 
a fibroid and chronic septicaemia. 

Some time ago I was called in consultation to the bedside of a lady who 
was dying of general peritonitis, which had arisen one week after the removal 
of a sponge-tent employed for dysmenorrhea by her physician, who was a 



TENTS. 97 

most careful and competent practitioner. Besides these cases, I have seen, as 
has every other gynecologist who has employed this means to any extent, a 
number in which the following affections have been excited by tents : pelvic 
peritonitis, peri-uterine cellulitis, septicaemia, endometritis, and hematocele. — 
T. G. T.] 

[I have seen a similar experience, within the last two years, of death 
from general peritonitis after a succession of tupelo tents, where I was 
fortunately able, by my testimony before a coroner's jury, to secure the 
acquittal of the physician. — P. F. M.] 

This is the record of our own practice, and our observation of that 
of many of our friends whose results we have had an opportunity of 
seeing exactly agrees with it. Let it be remembered that many of 
the operations of gynecology are performed after dilatation of the cervix 
by tents. A fatal result ensuing is commonly attributed to the opera- 
tion. With our experience we cannot doubt that the preparatory dila- 
tation is accountable for it in many cases. 

In view of the great suddenness with which the dangerous symp- 
toms which follow the use of tents develop themselves, we feel con- 
fident that they are due to the formation of a septic infection, the 
germs of wdiich probably came from without, and which spreads to the 
peri-uterine cellular tissue and adjacent peritoneum by means of the 
lymphatics, exciting both septic peritonitis and general septicaemia. 
We will not deny the possibility of the infection spreading from the 
endometrium through the Fallopian tubes in some cases. 

This subject is one of so great importance that we deem it best 
before leaving it to enumerate certain rules which should always govern 
the practitioner who resorts to this valuable, but at the same time 
unquestionably hazardous, method of diagnosis and treatment : 

1st. In the introduction of a tent no force whatever should be 
employed. Should that first essayed not pass the os internum easily, 
it should be at once withdrawn, and either bent so as to follow more 
accurately the course of the cervical canal as ascertained by the probe 
or exchanged for a small tent. 

2d. A tent should never, under any circumstances, be introduced at 
the physician's office and the patient allowed to go home with it in 
utero. Such practice is hazardous in the extreme. Even when intro- 
duced at the patient's home, she should at once be confined to the 
recumbent posture and kept perfectly quiet. The tent should be 
covered with carbolized vaseline. 

3d. The practitioner should always investigate as to the previous 
existence of chronic pelvic peritonitis or cellulitis, two of the most com- 
mon of the diseases of women. Should they have existed, tents should 
be carefully avoided. In most of the instances in which we have seen 
dangerous results follow their use one of these conditions had previously 
existed and been excited into activity by them. 

4th. A tent should never be allowed to remain in the uterus more 
than twenty-four hours, and if it be compatible with the accomplish- 
ment of the desired result it should be removed in twelve hours. 

5th. Just before and just after the removal of a tent the vagina 
should be washed out with an antiseptic fluid, and if any pain, chilli- 

7 



98 MEANS OF DIAGNOSIS. 

ness, or discomfort follow the removal, opium should be freely admin- 
istered and perfect quietude enjoined. 

6th. After removal of a tent the patient should be kept in bed for 
at least twenty-four hours, and never allowed to travel before the 
expiration of four or five days. 

We are fully aware that these precautions will be incredulously 
received by those practitioners who have habitually and with impunitv 
inserted tents at their offices and sent the patients home with directions 
to remove them, by means of the cord, on the next day. But it is 
the duty of every conscientious man to give weight to the experience 
of others. If it were essential for every practitioner to lose one patient 
from this or any kindred cause before regarding it as really dangerous, 
the number of fatal cases would necessarily grow very large. 

[Note. Since the last edition, Dr. Thomas's position in regard to tents 
has changed to such a degree that in a communication on the subject received 
from him after this chapter had gone to press he says : " Tents of all kinds 
should be discarded in gynecology, absolutely and completely. Dilatation 
of the os and cervix uteri can be more certainly and safely accomplished by 
rapid dilatation by the divulsor, under anaesthesia and careful antisepsis, 
and should always be practised by preference.'" I personally am not pre- 
pared to go as far as this, and should be sorry to be compelled to part with 
the tupelo tent in certain cases where a gradual, slow, and thorough dilata- 
tion is desired. Sponge and laminaria I have not employed for years. Feel- 
ing that a sweeping condemnation of tents in gynecology would scarcely 
meet with the approval of the profession, and believing, as I do, in their 
limited utility, I have thought it my duty to endeavor to instruct the prac- 
titioner how to use them with as little risk as possible, and have therefore 
retained this section. — P. F. M.] 

The Dull Curette. — In cases where profuse menstruation or an 
offensive discharge from the uterus leads one to suspect the presence of 
small vegetations or polypoid degeneration of the endometrium, or possi- 
bly malignant disease, the dull curette may be passed up into the uterine 
cavity, and the latter gently scraped by repeatedly drawing the instru- 
ment from the fundus down to the internal os. The discharge which 
then always escapes from the external os, on being mopped up with 
cotton in a dressing-forceps and examined by the eye, will frequently 
show the presence of small shreds or bits of tissue of the size of a 
canary-seed — namely, the adenoid degeneration referred to, which is 
the cause of the menorrhagia. The diagnosis is thus made by the 
curette, and the treatment will consist in a thorough removal, by the 
same or a more powerful instrument, of all the diseased tissue. If the 
curette removes other shreds of a different appearance, which under the 
microscope prove to be malignant, the diagnosis has likewise been made 
by the instrument. Another variety of adventitious tissue which may 
also cause bleeding or offensive discharge is that left behind after a con- 
finement, usually a miscarriage — namely, a portion of the placenta or 
ovum ; and here, too, the dull curette affords a valuable if not indis- 
pensable means, not only of making a diagnosis, but also of removing 
the offending substance. A larger curette with longer handle, the 



THE ASPIRATOR. 99 

whole instrument measuring sixteen inches in length, is used for this 
latter purpose. 1 

The Exploring Needle. — By means of a long delicate needle or 
very narrow tube, constituting a canula for a trocar the size of a small 
knitting-needle, the contents and characters of tumors in the pelvis 
may be ascertained. These instruments are not employed in treating 
cysts, but are required only to remove sufficient fluid to announce the 
character of the contents of the tumor. Sometimes a tumor supposed 
to be solid and irremediable is thus proved to be amenable to treatment. 

The Aspirator. — To whom belongs the credit of originating this 
method of evacuting the fluid contents of tumors or cavities we are 
unable to say. M. Courty alludes to it as a method of emptying- 
ovarian cysts in use ten years before the appearance of his work, and 
mentions the instruments employed for that purpose by Buys, Monro, 

Fig. 28. 




Potain's Aspirator. 

Guerin, and Boinet. To Dieulafoy and Potain of Paris certainly belongs 
the credit of systematizing and popularizing it to such an extent that 

1 See Munde: "The Immediate Removal of the Secundines after Abortion. 
Joimi. Obstetrics, Feb., 1883. 



Arm 



100 MEANS OF DIAGNOSIS. 

it must be looked upon as a great resource, not only for the diagnosis, 
but also for the treatment, of many of the morbid states with which the 
gynecologist is called to deal. 

This method consists in the introduction of very slender, long 
needles, perforated by a capillary tube, into tumors in regard to the 
characters of which it is desired to decide ; connecting these by gutta- 
percha tubes with a glass cylinder in which a powerful piston plays very 
accurately ; and creating a vacuum in this by drawing the piston upward. 
Powerful suction is thus exerted upon the material in the cavity pene- 
trated by the needle, and, if it consist of fluid not too tenacious to flow 
through so small a needle, it passes through the tube and enters the 
cylinder. Such instruments, very perfectly constructed and more or 
less simplified, can now be obtained of the instrument-makers of any 
city. 

One great advantage possessed by this instrument consists in the 
fact that the needles are so delicate that the intestines, the bladder, 
solid tumors, or even important secreting organs, may be penetrated 
without great danger. The sac imprisoned in intestinal hernia, the 
large intestine distended by gases, the bladder threatened with rupture 
through impassable stricture, have all been tapped by it with impunity. 

Should the operator not have this instrument at his disposal, the 
same principle may be applied to diagnosis by the use of the ordinary 
hypodermic syringe, as suggested by Dr. H. F. Walker, and sufficient 
fluid obtained for chemical and microscopical examination. 

This method of exploration may be applied to all pelvic and abdom- 
inal tumors with the best results. 

In the use of the aspirator too much care cannot be observed as to 
cleansing the needles before introducing them. The fluid of ovarian 
cysts is often withdrawn by them, then the needle used is carelessly 
washed, put aside, and again used, at the infinite risk of contamination 
of another patient. Not only should the needles be scrupulously 
cleansed after, but before, being used, and immediately before intro- 
duction they should be dipped in a carbolized solution. The best 
means of ensuring their absolute cleanness is to heat them thoroughly 
in a spirit-lamp just before using them. 

The Microscope. — The microscope will often prove useful as an 
aid in diagnosis in determining the malignant nature of certain morbid 
growths, the character of products of inflammation, the connection of 
an intra-uterine growth with conception, the purulent nature of uterine 
leucorrhoea, and the deleterious effects of uterine discharges upon the 
zoosperm in the production of sterility. In several cases of obstinate 
metrorrhagia dependent upon an unascertained cause Ave have been 
able, through cervical dilatation and the use of the curette, to obtain 
material sufficient for a positive diagnosis of sarcoma or cancer of the 
body by this instrument. 

[One case has come to my knowledge in which many of the symptoms 
of cancer of the body existed, but in which the error in diagnosis thus 
created was corrected by a removal of a portion of the supposed morbid 
growth and examination by the microscope. By this instrument the sub- 



AUSCULTATION AND PERCUSSION 101 

stance was pronounced to be not cancer, but sponge, and further investigation 
proved that one-half of a sponge tent had remained in the body of the 
uterus for several months. A similar case has been reported to me in 
which a piece of cotton was long retained, giving rise to very anomalous 
symptoms. A portion being removed, the microscope revealed its true 
nature.— T. G. T.] 

Foulis and Thornton have pointed out the important fact that 
examination of the abdominal effusion accompanying cancer of the 
ovaries reveals the cancer-cell and leads to a correct diagnosis ; and 
Drysdale has proved the great value of the microscope in examination 
of ovarian fluids and the determination of the diagnosis by them. 

Auscultation and Percussion. — The important assistance of 
auscultation and percussion in mapping out the size of tumors, deter- 
mining pregnancy, differentiating this from ovarian cysts, etc., is so 
evident as merely to require a passing mention. 



RECAPITULATION OF MEANS FOR EXPLORING THE VISCERA AND TIS- 
SUES OF THE PELVIS. 

1st. Vagina and Cervix : 
Vaginal touch ; 
Sight, through the speculum ; 
Conjoined manipulation. 

2d. Outer Surface of the Uterus: 

Vaginal and rectal touch, while the organ is brought within 

reach by hypogastric pressure or the tenaculum ; 
Conjoined manipulation; 
Vesico-rectal exploration ; 
Simon's method. 

3d. Cavity of Cervix and Body: 

Tents, followed by introduction of finger ; 

The uterine probe and sound ; 

Removal of substance by curette and use of microscope. 

4-th. The Ovaries, Tubes, Broad Ligaments, Pelvic Peritoneum, 
Pelvic Areolar Tissue, and Ureters : 
Vaginal touch ; 
Rectal touch ; 
Simon's method ; 
Conjoined manipulation ; 
Abdominal palpation ; 
Auscultation and percussion ; 
The exploring needle ; 
The aspirator. 

[It is so difficult for a teacher to give instruction to a class upon the 
subject of diagnosis of the diseases of women that I am induced by that 



102 



ELECTRICITY IN GYNECOLOGY. 



consideration to give a representation of a manikin figure which has given 
me great satisfaction in this connection. 

This figure is made of thick board, painted to resemble the human 
female, the legs being articulated, and the whole fixed to a table like that 
represented in Fig. 8. Upon the part representing the trunk all the 
abdominal, thoracic, and pelvic organs are painted except the uterus. In 




Manikin Figure for Teaching Diagnosis. 

place of this a peg or pivot is fixed, and upon this uteri, of all shapes and 
sizes, flexed, with tumors, enlarged, inverted, etc., may be fixed to illustrate 
cases presenting themselves clinically. After examination on the back, the 
figure is placed in Sims's position, the table elevated at one side, and the 
speculum and sound are employed. The sense of sight is made to supple- 
ment that of hearing, and instruction is made clearer by this means. — 
T. G. T.] 



CHAPTER VI. 



ELECTRICITY AS A THERAPEUTICAL AGENT IN GYNECOLOGY. 



Electricity as an agent in the treatment of various diseases of 
the female pelvic organs has attained such prominence during the 
past decade that we have thought it proper to devote a brief chapter to 
its discussion. It is true there are still many gynecologists w T ho do not 
believe in its particular efficacy, partly because they have either had 
no experience w r ith it or because many of the most startling results 
have been reported by gentlemen who were not gynecologists, but 
electricians, or, better, electrologists, who possibly may have been mis- 
taken in their diagnoses and in the results which they claimed to 
have obtained. Still, Ave feel confident from our own experience that 
w T e have in the two varieties of the electrical current most potent 
agents for relief from suffering, and perhaps even cure, in many cases 
of pelvic disease in the female. As is well known, these two varieties 
of electricity are the faradic or interrupted and the galvanic or con- 



ELECTRICITY IN GYNECOLOGY. 103 

stant current. Both differ decidedly in their indications for use and in 
their effects on the human system. 

The faradic current, as a rule, may be considered to be an irritant, 
a stimulant, a promoter of increased vascular action in the parts through 
which it passes. In certain cases it is true, however, that it acts as a 
sedative and allays pain. The faradic current, therefore, will usually 
be indicated in cases where it is desired to increase the vitality, the 
growth, the blood-supply of an organ. On the whole, the faradic cur- 
rent has, in our experience, a far more limited application than the 
galvanic current in the treatment of the diseases under our consid- 
eration. 

The galvanic current is chiefly indicated where it is desired to pro- 
duce a sedative, an alterative, or an absorbent effect upon the tissues, 
and therefore will be employed in conditions where it is essential to 
melt away tissue which is in excess or is the result of old inflammatory 
processes. 

Use of the Faradic Current. — For the ordinary necessities of 
gynecological practice we have found the well-known Kidder tip battery 
to answer every purpose. Faradic batteries made by other companies, 
however, do very well, and we have no desire to claim any preference 
for one kind of instrument over another. Two cords with round 
sponges attached to universal wooden handles, a copper or steel properly 
insulated uterine sound, and a ball electrode for use in the vagina, con- 
stitute about all the apparatus that is needed for the proper application 
of the faradic current to the female sexual organs. Specialists in 
electro-therapeutics have devised numerous other complicated instru- 
ments for the passage of the current in different directions through the 
uterus, ligaments, vagina, and rectum ; but we confess that we have 
not found it necessary to go into such details in order to achieve satis- 
factory if somewhat limited results. 

The diseases in which the faradic current will be found useful are 
the following : deficient development of the uterus and ovaries, amen- 
orrhoea, subinvolution, menorrhagia, superinvolution, uterine displace- 
ments, uterine fibroids (interstitial and submucous). In all these dis- 
eases it should be distinctly understood that only perseverance and a 
thorough trial of the treatment will result in benefit, if indeed such is 
to be achieved by this method. The action of the faradic current in 
deficient development of the uterus and ovaries, amenorrhoea, and 
superinvolution is to stimulate the organs to increased growth by local 
irritation and by augmenting their supply of blood. In subinvolution 
and uterine fibroids the current acts by contracting the uterus — in the 
one case with the object of restoring it to its normal ante-pregnant 
condition ; in the other of either interfering with the nutrition of the 
fibroid by its compression between the muscular fibres, or possibly by 
forcing the tumor into the uterine cavity and eventually out through 
the external os. Sittings should be given at least every other day — 
better every day — from five to fifteen minutes each, the current used 
being as strong as the patient can support. The internal electrode 
should usually be the sound, and the external a sponge placed over 



104 



ELECTRICITY IN GYNECOLOGY. 



either the fundus uteri on the abdomen, or over each ovarian region 
alternately, as the cases may demand; or the current may also be 
passed through the sacral and lumbar portions of the spinal cord, bv 
means of a large flat sponge on the back, in case it seems desirable to 
excite these nervous centres. In displacements of the uterus the 
electrodes should be so placed as to pass the current through the lig- 
aments and muscles which it is desired to excite to contraction or to 
strengthen. In cases of prolapsus of the uterus and vagina some ope- 
rators have reported good results from the use of a finger-shaped metal 
electrode in the vagina, by means of which the vaginal walls were con- 
tracted and restored to their original tone. * The faradic current has 
been of particular service to us in cases of irregular (infrequent) and 
scanty menstruation, due either to torpidity of the ovaries and uterus 
or to an imperfect development of those organs. We have thus seen 
sterile women who menstruated only every three or four months, after 
a treatment of several months with the faradic current, as above 
described, begin to menstruate regularly, and eventually to conceive. 
The same agent has also been fairly successful in our hands as an aid 
to the expulsion of submucous fibroids in conjunction with the steady 
use of ergot and repeated dilatation by tupelo tents. 



The Constant Current.- — For the constant current we use a station- 
ary battery of either forty or sixty Leclanche elements, or if the 
agent is to be used outside of our offices and sanitariums, a thirty- 
six-cell battery constructed on similar principles. So many of these 
instruments are now made by different manufacturers with various 
arrangements for office use that we will not attempt to influence the 
choice of one particular battery over the other ; we have found those, 
however, made by Waite & Bartlett of New York to answer all our 
requirements. Besides the battery, there are required a galvanometer 
or milliamperemeter graduated to a scale of at least 250 ; further, a 
Bailey rheostat, through which the whole current is passed, its strength 
being controlled by the gradual depression of the carbon plate of the 
rheostat into water, the number of milliamperes being marked on the 



Fig. 30. 




Vaginal and Cervical Electrodes, with Universal Handle. 

galvanometer. In this way all interruptions of the current from the 
old method of moving the indicator forward from cell to cell are 
avoided — a matter of great practical importance and saving of much 
pain to the patient. Further, a steel or copper properly insulated 
sound ; a metal ball electrode for the cervix and vagina, to be covered 
with absorbent cotton when used ; a couple of large flat sponges for 
use on the abdominal walls or the sacrum ; four or five silk-covered 



ELECTRICITY IN GYNECOLOGY. 



105 



wire cords; and perhaps a cup electrode for the cervix uteri, complete 
the usual outfit. If the electrolytic treatment is to be employed for 
uterine fibroids, a sound, of which at least two and a half inches are 
composed of platinum, the rest properly insulated, several lance-shaped, 
properly insulated needles for vaginal galvano-puncture, and a large flat 
pad of clay, two feet by one, contained in a linen bag, will be required. 
These latter instruments are thus used and recommended by Apos- 
toli of Paris, but they are now made by nearly all instrument-makers, 
with more or less modifications and improvements. It is not very 
difficult to learn the construction and management of these batteries 
and instruments, and by no means requires a skilled and practised 

Fig. 31. 



WAITE & BARTLETT MANT'G.CO. O N.y. 




Vfunde's Lance and Spear-pointed Needles, with Handle, for Vaginal Electro-puncture (natural 

size). 

electrician in order to know how to use them intelligently and with 
benefit to the patient. But, a certain amount of experience is 
undoubtedly necessary in order to know exactly in what cases the 
treatment is likely to be beneficial or where it may do no good, or 
even be injurious, and of course the operator must know when his 
battery is not doing its work properly — a fact which is very easily 
ascertained in the faradic battery by the weakness of the current as 
experienced by the patient, and in the galvanic battery by the failure 
of the milliamperemeter to record the number of milliamperes which a 
certain number of cells have been known before to give. The galvanic 
battery particularly needs more or less frequent refilling and cleaning. 
The so-called storage-batteries which are used for electric lighting and 
motion are, we believe, so constructed that they can be left alone for a 
long period and yet still retain all their power, and many electro-thera- 
peutists have these batteries connected with their office-indicators and 
use them for treatment. 

In the faradic current it makes no difference practically which pole 
touches the internal organ or the skin. With the constant current, 
however, this is a matter of very great importance, which will he 
readily understood when we state that the positive pole exerts a sooth- 
ing, sedative, hemostatic influence, whereas the negative pole is irri- 
tating, alterative, and caustic. As a rule, therefore, the positive pole 
is used in the uterine cavity and the negative pole on the skin. Fur- 
ther, whereas with the faradic current the sensations of the patient 



106 ELECTRICITY IN GYNECOLOGY. 

will be the almost exclusive sign for the limitation of the strength of 
the current, with the galvanic current the strength of the application 
is gauged in all cases where a gentle, soothing, and alterative effect 
alone is desired, partly by the sensations of the patient and partly by 
the galvanometer ; in the other instances, where a powerful electrical 
or absorbent action is intended, the current will be given very much 
stronger, its intensity being then measured entirely by milli amperes, 
often going as high as 250 ma., which will be more than most patients 
will be likely to stand except under anaesthesia. This applies chiefly 
to the electrolysis of fibroids. 

Diseases in ivhich Galvanism is Indicated. — Hyperplasia uteri ; 
chronic ovaritis and pachysalpingitis ; chronic cellulitis and peritonitis 
and lymphadenitis ; pelvic neuralgia, local and reflex ; dysmenorrhea, 
neuralgic and obstructive ; erosions of the cervix ; subinvolution ; 
uterine fibroids. 

In hyperplasia uteri, if the object is to reduce the size of the ute- 
rus and bring about absorption of the hyperplastic areolar tissue, the 
negative pole should be used in the uterus, the positive on the abdo- 
men ; but if the object is to relieve the local and equally "distressing 
reflex pains so common in this affection, the positive pole should be 
intra-uterine. In chronic oophoritis and pachysalpingitis (pachysalpin- 
gitis meaning hyperplasia of the wall of the tube as the result of 
acute and subacute inflammation of the organ), the positive pole should 
be a metal ball electrode covered with absorbent cotton and applied to 
the vaginal vault of the affected side, the negative on the abdomen. 
The current, being chiefly used to relieve pain, and perhaps eventually, 
in recent and not very severe cases, produce an absorption of the 
adventitious tissue, should never be so strong as to give rise to pain ; 
on the contrary, it should soothe and relieve. We have seen many 
such patients, suffering acutely when they entered our office, leave it 
absolutely free from pain after a fifteen minutes' treatment with the 
galvanic current at a strength of from 15 to 20 ma. Of course this 
benefit w T as but temporary, but even that small amount of relief Avas 
gratefully welcomed by these patients, to whom the dread of the other- 
wise inevitable operation was ever present. We know of one case cer- 
tainly in which this treatment, continued without interruption for over 
three months, together with the use of iodine to the vaginal vault and 
blisters to the ovarian regions, resulted in a complete and permanent 
cure of as distinct and decided a salpingo-obphoritis as we ever saw (P. 
F. M.). 

Chronic pelvic cellulitis and peritonitis, pelvic neuralgia, local and 
reflex, pelvic lymphadenitis and lymphangitis, — in all these three condi- 
tions the local and reflex pains are mostly due to inflammatory indura- 
tions and adhesions of the tissues involved. The vaginal roof is hard 
and rigid, the uterus immovable, perhaps displaced, and the uterine 
ligaments tense and inelastic. If not of too long duration, and par- 
ticularly if the exudation represents a distinct swelling, the galvanic 
current may effect decided results. As usual, the positive pole should 
be placed at the spot where the pain is felt, which is in the vagina (the 



ELECTRICITY AS A THERAPEUTICAL AGENT 107 

metal ball is covered with absorbent cotton in order to prevent its 
burning the mucous membrane ; for even the positive pole, if strong 
currents are used or the applications are frequently repeated, will pro- 
duce an eschar unless the metal is covered with some protective sub- 
stance). We have seen a most intractable and excruciating sciatica, 
resulting from the pressure of a pelvic exudation, entirely cured in three 
sittings by the galvanic current with the positive pole in the vagina, the 
negative on the hip over the ischio-sciatic foramen. The negative pole, 
first used internally in this case, only aggravated the pain (P. F. M.). 

In obstructive and neuralgic dysmenorrhcea the galvanic current 
should be used by means of a sound (positive pole in the neuralgic, and 
negative pole in the obstructive, variety) in the uterus, and the other 
pole on the abdomen. In the obstructive variety, where it is desired 
to render the canal patulous and to keep it so, a stronger current would 
probably be required than in the neuralgic form, where the object is 
merely to soothe and relieve pain. Erosions of the cervix in nul- 
liparous women we have occasionally seen benefited by placing the 
uncovered metal ball of the negative electrode against the erosion, the 
positive pole on the abdomen, and passing a current of from 30 to 50 
ma. for ten to fifteen minutes. 

It must be understood that the use of the galvanic current in all 
of the above-mentioned affections will be practically without avail 
unless it is carefully, scientifically, and systematically used for at least 
several weeks, perhaps even several months. As a rule, a few applica- 
tions will neither benefit nor injure. Once in a while we meet with a 
case of chronic pelvic inflammation where the galvanic current aggra- 
vates the pain and has to be abandoned. 

We come now to the consideration of the use of the galvanic current 
in fibroid tumors of the uterus — a subject which, thanks to the indefati- 
gable efforts of its originator, Apostoli, and his disciples, has during the 
last few years excited more attention than any one other gynecological 
topic. His treatment consists in passing through the uterus and tumor, 
by means of a pure platinum sound inserted into the uterine cavity 
(positive pole) and a large wet clay electrode on the abdomen (negative 
pole), a current of galvanic electricity varying from 50 to 250 or even 
more milliamperes. This treatment is to be repeated as often as the 
patient can bear it, each sitting extending from five to ten minutes, 
according to the strength of the current, and at least from thirty to fifty 
sittings being given before a positive result is to be expected. By means 
of this treatment he claims not only to arrest hemorrhages and relieve 
pain, but also to reduce in very many instances the size of the tumor, 
and even in a certain proportion to bring about its entire absorption. 
We have visited his clinic, and, judging by plaster casts of cases which 
he showed us, made when the treatment was besnin, and the size of 
the tumors at our visit, we cannot deny that his statements are based 
upon facts. We have ourselves employed the method in a sufficiently 
large number of cases to be able to judge of its value : but, while we 
have certainly seen the bleeding more or less controlled and the pain 
very much relieved, we cannot speak in equally favorable terms of our 
results in reducing the tumors. We think that the method has 



108 ELECTRICITY AS A THERAPEUTICAL AGENT. 

undoubted advantages — that it will in all probability do good in very 
many cases, particularly of soft interstitial myomatous growths, chiefly 
by controlling bleeding and relieving pain ; but we doubt very much 
whether it will prove to be of decided and permanent benefit in secur- 
ing the absorption and entire cure of these growths. 

It has a few dangers — namely, the possibility of producing peri- 
tonitis and of causing intra-uterine sloughing and septicaemia, several 
cases of which have been reported as due to this treatment. 

The method has found many enthusiastic advocates, among whom may 
be mentioned so great a hysterectomist as Thomas Keith, and is being- 
tested in this country with great thoroughness and zeal by many prom- 
inent gynecologists and electrologists. We must wait for further and 
more extended reports, not only as to immediate results, but as to the 
permanency of such results, before considering the question entirely 
settled. 

As long ago as 1876, Cutter and Kimball of Massachusetts reported 
a series of cases in which they performed electrolysis of fibroid tumors by 
piercing the growth through the abdominal wall with two large gutter- 
shaped daggers. They had some excellent results, perfect cures, but 
they had more failures and a not inconsiderable proportion of deaths 
from this treatment. Nowadays only the more venturesome members 
of our profession indulge in this abdominal galvano-puncture. 

We ourselves have many times punctured such fibroid tumors as 
were safely reached through the vagina with lance-shaped needles insu- 
lated up to within one inch of the point, passing one needle about two 
inches into the tumor and using the positive pole, with the negative 
pole as a clay pad on the abdomen. The patient was usually anaesthe- 
tized, and a current up to 250 ma. was passed through the tumor for 
at least five minutes. By this method we have absolutely cured five 
large both hard and soft tumors, which, at periods varying from one to 
two years after cessation of the treatment, were found to have entirely 
disappeared. The number of punctures varied from two to six, given 
at intervals of one week under the usual careful antiseptic precautions, 
the patient being kept in bed for at least two days after each applica- 
tion, with an ice-bag on the abdomen. In one case, it is true, slough- 
ing of the track of the needle-punctures took place, with subsequent 
sepsis, which required free incision and curetting of the sloughing cav- 
ity ; after this the patient rapidly improved, and the tumor was found 
six months afterward to have entirely disappeared. The sloughing may 
in this case have had something to do with the absorption. In another 
case during the past winter the electro-puncture produced a large abscess 
in the tumor, which was opened by the vagina. For a time the tumor 
diminished, but at last accounts was again growing rapidly. But the 
patient's health had greatly improved. 

The number of fibroid tumors in which this vaginal puncture is 
practicable must necessarily be more or less limited, and care must be 
taken before introducing the needle to ascertain the position of the 
bladder by exploring it with the sound. We have seen one instance 
of a vesico-vaginal fistula produced by a slough from the needle, which 
was introduced too close to the wall of the bladder by a general prac- 



CONGENITAL AND INFANTILE MALFORMATIONS. 109 

titioner. We had the pleasure of eventually closing the fistula. We 
consider this method by far more powerful and more likely to cause 
absorption of the tumor than the plain intra-uterine or true Apostpli 
treatment. It is, of course, also more risky, for the reasons already 
adduced ; but still, in favorable cases, we think it worthy of trial. 

Our confidence in the use of electricity for the diseases mentioned in 
this chapter is based upon an experience of nearly twenty years, during 
which time we have, of course, learned to use it more scientifically, 
more carefully, more intelligently, especially since we have been able 
to dose the current accurately by the help of the galvanometer ; and 
while we may not be inclined to place as much faith in its curative 
properties in cases of old pelvic inflammatory conditions as we used to 
do, now that laparotomy has shown us how safely and speedily we 
can cure diseased appendages with the knife, we are still not inclined 
to retract substantially what we have written on the subject in past 
years. 1 



CHAPTER VII. 

CONGENITAL AND INFANTILE MALFORMATIONS OF THE FEMALE 
SEXUAL ORGANS; HERMAPHRODISM. 

Many cases of disease are due to congenital malformation of the 
ovaries or uterus, or to deformities arising from arrest of or dispro- 
portionate development during girlhood. Up to the period of puberty 
the uterus, ovaries, and vagina are unimportant organs in the female 
economy. At that time they rapidly develop and immediately assume 
most important relations. During their period of insignificance, even 
if the most striking malformation exist it produces no evil result, and, 
unless some accidental circumstance reveal it, is not recognized or even 
suspected. Puberty arrives, the girl becomes a woman, and all is 
changed. Upon the efficient performance of the functions of ovula- 
tion and menstruation are, for the next thirty or thirty-five years, to 
depend in great degree the health, the usefulness, and the happiness 
of the woman. 

Preparatory to the performance of these functions the pelvic viscera 
have been steadily though very slowly developing, and now with great 
suddenness an important duty is thrown upon them. If during uterine 
life their development has been defective, or if during the period inter- 
vening between birth and puberty they have either not sufficiently 
grown or have grown in such a manner as to be misshapen, then are 
they incompetent to the performance of the duties required of them. 
and certain diseased conditions are the result. 

We shall consider only the most important of these, and it must 
be borne in mind by the student that their importance must not be 
estimated by the possibility of their relief. The recognition o\' the 

1 See Munde on " Electricity as a Therapeutical Agent in Gynecology," Amer. Journ. 
Obstetrics, Dee., 1885, 41 pp. ; and the same, " My Recent Experiences with Electricity 

in Gynecology," ibid., June, 1890. 



110 



CONGENITAL AND INFANTILE MALFORMATIONS 



fact that a pathological state is irremediable, and that treatment for it 
is unadvisable, is always a matter of as great moment as the ascertain- 
ing that a more fortunate state of aifairs exists. In all departments of 
medicine, but especially in gynecology, treatment which accomplishes 
no good necessarily tends to the production of evil. 



Development of Generative Organs. — In the lumbar regions of the 
foetus, before the end of the second month, the anatomist Wolff dis- 
covered two bodies, each consisting of a large number of tubes closed 
at one extremity and by the other opening into a common excretory 
canal. These have since been known as the "Wolffian bodies, and from 
them essentially spring the male internal organs of generation, but not 
so the female. At the inner border of each Wolffian body lies a germ 
which, remaining unchanged until the second month, develops into the 
ovary of that side, while the Wolffian body gradually becomes atrophied. 
From the inner sides of these descend two ducts, called the ducts of 
MUller, which passing downward side by side, unite at a point just 

below one where the urethra of 
the foetus begins to show its rudi- 
mentary formation. At about the 
end of the second month these ducts 
begin to approach each other more 
nearly at a point in the pelvis, and, 
gradually coalescing and their inner 
walls disappearing, the vagina and 
cervix, and, at a later period, the 
corpus uteri, are created. The up- 
per portions of the ducts, passing off 
to each side obliquely, constitute in 
the future the Fallopian tubes. Fig. 
32 will show the coalescence of the 
Mullerian ducts in the foetal. sheep. 
A rudimentary vagina, Fallopian 
tubes, and uterus are thus formed, 
and gradually go on to full development during the rest of foetal life. 
Any arrest of development affecting the ducts of Miiller, any imper- 
fection of them, or any failure in coalescence of the two ducts, even 
when fully developed, inevitably gives rise to malformation or deformity. 
Some of these produce grave consequences at puberty ; others are so 
wanting in result that the functions of the woman are healthily per- 
formed in spite of them. Their very existence even may never be 
revealed, or be discovered only by accident toward the end of or after 
menstrual life. 

The varieties of congenital malformation of these parts which we 
shall consider are the following : 
Hypertrophy of the uterus ; 

Absence or rudimentary state of uterus, ovaries, or vagina ; 
Unicorn and bicorn uterus ; 
Double and divided uterus and vagina ; 
Congenital misplacement of the uterus. 




Coalescence of Mullerian Ducts in a Foetal 
Sheep (I. Miiller). 

a, a, Wolffian bodies: b, ureters; c, c, ovaries; d, 
d, parovarium; /, e, Fallopian tubes; g, coa- 
lesced Muller's ducts, forming uterus and va- 
gina. 



OF THE FEMALE SEXUAL ORGANS. 



Ill 




112 



CONGENITAL AND INFANTILE MALFORMATIONS 




OF THE FEMALE SEXUAL ORGANS. 113 

Hypertrophy may affect the foetal uterus and ovaries, and as a result 
the child be born with this organ and the external genitalia as fully 
developed as they should normally be at puberty. In these monsters 

Fig. 35. 




/k^ 



A. S , aged four years and nine months, menstruated regularly from the age of twenty-one 

months. 



by excess of development the most remarkable sexual precocity some- 
times shows itself. Instances are recorded in which menstruation began 
at birth or Avithin a month after, and one case of undoubted authenti- 
city is reported in which, menstruation beginning at two years, parturi- 
tion at full term occurred when the mother was only eight. Fig. 35 
represents a girl whose case was brought to our notice some years ago. 

We have seen another case in which menstruation began at eight 
months and continued regularly. 

Absence, and Rudimentary Development, of Uterus and Ovaries. — 
At times an entire failure, not only of coalescence, but of development, 
occurs in Miiller's ducts. The Fallopian tubes, uterus, and vagina are 
all absent, and very often in such cases the ovaries likewise. In other 
cases the uterus is absent, while the vagina, Fallopian tubes, and ova- 
ries are developed, coalescence of the ducts having failed while devel- 
opment above and below has occurred. 

Entire absence of the uterus, tubes, and ovaries, as proved by post- 
mortem examination, not by physical exploration during life, is o^ 
so rare occurrence that some pathologists have doubted its existence. 
When it occurs it usually does so in infants who suffer from want o\' 
development of the lower half of the body. It must be borne in mind 
that sometimes rudimentary uterine horns exist, which in a physical 
examination cannot, even by the most practised touch, be distinguished 
from portions of the oviducts and ovaries. In some cases ot" undoubted 



114 



CONGENITAL AND INFANTILE MALFORMATIONS 



Sk^ 




Bow-shaped Rudiment of Uterus (Nega). 



rudimentary uterus only a slight nodular hardness can be discovered 

where the uterus should be, 

which feels like an aggregation 

of areolar tissue only. There 

can be little doubt that these 

cases are clinically often classed 

with those of absence of the 

uterus. 

The rudimentary uterus is 
often accompanied by a similar 
condition of the ovaries, vagina, 
and even the mammae and exter- 
nal genitalia. In such cases the 
vagina will often be found as a 
cul-de-sac measuring only one 
or two inches. This, however, 
under sexual efforts long and per- 
severingly continued, often un- 
dergoes great elongation and development. When this fails the urethra 
sometimes undergoes dilatation, and, being penetrated by the virile 
organ, acts as a vicarious vagina. 

The rudimentary uterus usually appears under one of these forms : 
a thin membranous expansion spreads from the extremities of the Fal- 
lopian tubes and round ligaments toward the vagina ; a round, hard, 
two-horned solid body marks the site of the uterus ; a flattened, cres- 
centic line of tissue occupies the site of the uterus, extending across 
the pelvis with its convex surface looking upward ; the cervix being 
entirely wanting, the semblance of a body is present without a cavity ; 
the body with cornua exists, but without perforating canal ; or, lastly, 
the cornua exist with cavities within them, while the body and cervix 
uteri are both very rudimentary in their development. 

Since the days of modern gynecology this anomaly has been found to 
be of not very rare occurrence ; previous to that period many cases went 
undetected because uninvestigated. The attention of the physician is 
usually drawn to their existence by the fact that the girl, arriving at six- 
teen or seventeen years, has never menstruated, and her relatives have 
become apprehensive ; or marriage is anticipated, and the girl or her 
mother, unwilling to assume its responsibilities while mystery exists 
with reference to so important a subject, desires investigation; or the 
girl, suffering from uterine enlargement, the result of retention of men- 
strual blood, is accused of illegitimate pregnancy, and is brought for the 
physician's decision of the matter ; or, worse than all, marriage has been 
contracted, the husband not having been candidly dealt with, sexual 
intercourse has been found to be impossible, and he brings his wife 
for examination. 

In such cases the physician's duty, if he be cognizant of the facts 
before marriage, is too clear to require mention. So grave does the law 
regard a fraud of this kind that it is considered a sufficient ground for 
divorce. The physician may likewise be consulted, as we ourselves have 
been five times, as to the propriety of marriage, the man knowing per- 



OF THE FEMALE SEXUAL ORGANS. 115 

fectly the imperfections of his proposed wife, and appreciating that not 
only are menstruation and conception impossible, but sexual intercourse 
likewise. As long as the laws of physiology hold true, so long will it 
be the duty of the medical adviser to oppose under such circumstances 
the contraction of a tie which must, unless the husband be more or less 
than man, prove in a short time a source of sorrow and disappointment. 

The evils which result from this distressing anomaly of sexual devel- 
opment are not merely the remote and contingent ones just mentioned ; 
there are others which are almost inherent to it. These are absent in 
the most decided cases of want of development, and present in those 
which are less complete. Thus if uterus, ovaries, and vagina be really 
absent or decidedly rudimentary, the woman may pass a long life, if she 
does not contract marriage, not only without suffering, but without know- 
ledge of her imperfection. If, however, a complete atresia exists in the 
lower portion of the uterus only or upper portion of the vagina, while 
the ovaries are sufficiently developed for ovulation to occur, menstrual 
blood collects, distends the uterine cavity, sometimes regurgitates through 
the tubes or ruptures them, or furnishes material for septic absorption. 

Such cases sometimes terminate fatally from these causes, and not 
rarely from the results of surgical procedures adopted for their relief. 
They will be elsewhere considered in reference to this aspect of the 
subj ect. 

Where the uterus is almost or entirely absent and the ovaries pres- 
ent, the most aggravated derangements of the nervous system — hysteria, 
epilepsy, and mental disorders — sometimes show themselves. [In such 
a case seen in consultation by Drs. Peaslee, Emmet, and myself, extir- 
pation of the ovaries was decided upon and performed by Dr. Peaslee. 
Unfortunately, the result was a fatal one. In a similar anomaly men- 
tioned by Duplay 1 a post-mortem examination gave unequivocal evi- 
dences of ovulation. Repeated small hematoceles must, of course, have 
been the consequence, as neither oviducts nor uterus existed. — T. G. T.] 

The question of treatment in such cases turns entirely upon the 
propriety of the surgical resource of opening a free passage through the 
atresic cervix uteri or vagina for the escape of menstrual blood already 
imprisoned, or for that which may be in the future excited to flow by 
therapeutic means adopted for that purpose. Before adopting — and, 
as is equally important, before discarding — these, a thorough explora- 
tion should always be made, and the manifold dangers of the opera- 
tion, together with its decided chances of failure, should be carefully 
considered. A great deal of unwarrantable surgery has been indulged 
in in such cases from neglect of these two duties. 

Physical Examination of such Cases. — The patient should be 
anesthetized, and placed upon the back upon a table and the legs 
flexed by two assistants. Then the sphincter ani being gently 
stretched, the index and middle fingers of the left hand should be car- 
ried far up the rectum, and conjoined manipulation carefully practised 
for detection of the uterine body. To this may be added the approxi- 
mation of the posterior wall of the bladder to the fingers in the rec- 
tum by a sound in the bladder, or, if necessary, by resort to introdue- 

1 Klob, Anal Fan. Sex. On/., p. 43. 



116 



COXGEXITAL AND INFANTILE MALFORMATIONS 



tion of the index finger of the right hand through the urethra in cases 
difficult of decision. There are no other means of physical explora- 
tion at our command, but these, intelligently practised, are very reli- 
able if preceded by anesthesia, as they should always be. 

But he who in these cases relies for his decision upon physical signs 
alone will surely be misled ; rational ones are of equal importance as a 
guide to surgical interference. A large hard, fibrous mass may be 
found in the position of the uterus, and yet the grave operation for atre- 
sia vaginae might not be advisable. If menstrual blood is discovered 
imprisoned, if a distinct period of excitement or discomfort marking 
ovulation can be traced, or if the otherwise perfect development, good 
health, and slight obstructive deformity which exist, all point to the 
probability that the hard mass in the site of the uterus is that organ 
with fair degree of development, the patient should be encouraged to 
submit to operation. If, on the other hand, there be no trace of accu- 
mulated menstrual blood, no evidences of an ovular nisus, and none by 
physical means of distinct presence of a mass in the uterine site, he who 
resorts to operation is exposing his patient to an unAvarrantable risk. 
Unicorn. Bicorn, Double, and Divided Uterus. — Sometimes the 
Mullerian ducts develop into the two halves of the uterus, but, coal- 
escing badly or the walls dividing 
tube from tube not being oblite- 
rated by absorption, deformities 
of less gravity than those just 
mentioned may result. One horn 
alone may develop, while the other 
fails to do so ; both horns may de- 
velop, but unite only at the cervix ; 
or both horns may develop, and, 
although they coalesce perfectly, 
their internal walls may not disappear, and thus a septum remain which 
divides the cavity into two. 

Fig. 38. 




Bicorn Uterus (Schroeder). 




Unicorn Uterus (Schroeder). 

The accompanying figures will give a very good idea of these 
deformities by arrest of development. 

The septum between the two vaginas may be perfect, or it may be 
absent at certain spots, and then the vagina there constitute but one 
canal. It is necessary to know this in order to understand how a 
vagina may be double in one part and otherwise single. 

Some of these deformities create great difficulties in diagnosis and 



OF THE FEMALE SEXUAL ORGANS. 



117 



curious problems in physiology ; such, for example of the former, as 
cases in which menstrual blood becomes imprisoned in one dilated ute- 
rine half, while the other remains empty ; and of the latter, instances in 

Fig. 39. Fig. 40. 





Double Uterus. (From specimen in posses- 
sion of T. G. T.) 



Divided Uterus (Kussmaul). 



which a child is born at full term from one uterine cavity, and in two 
or three months another from the other, or in which a white and 
a mulatto child, the offspring of different fathers, are produced at the 
same parturient act. 1 

Ordinarily, these malformations produce no evil, and it is probable 
that only a very small proportion of them come to the knowledge of 
the patient or physician. They require no treatment. 

Congenital Misplacement of the Uterus. — Sometimes the uterus is 
placed, by reason of its peculiarity of development, obliquely across 
the pelvis, inclining to one or other side ; or, one half developing more 
decidedly and rapidly than the other, a congenital latero-flexion exists ; 
or, the fundus being flattened, what is called the anvil-shaped uterus 
results. The chief importance of the recognition of these states is con- 
nected with prognosis and the futility of treatment for their removal. 

Absence and Rudimentary State of the Ovaries. — The ovaries, as 
well as the uterus, may be either 
not developed at all or very im- 
perfectly so. These organs arise 
about the end of the second 
month of foetal life from a germ 
at the side of the Wolffian bodies. 
As they develop, the outer cover- 
ing dips in, as shown in Fig. 41, to 
make the Graafian follicles, which 
contain the ova, the discharge of 
which at stated periods consti- 
tutes the great function of these 
glands and the characteristic fea- 




Development of Graafian Vesicles (Kuss., Phys- 
iology). 
0, 0, columnar epithelium covering cortical portion 

of ovary, drawn so us to show the difference between 

it and the flat epithelium of the peritoneum proper. 

which terminates in a circular line at the base of 

the ovary. 



1 Tli is last event may, however, be caused by superfecundation ; that is, by fruitful 
coition with a white man and a negro at a short interval, so that practically two sepa- 
rate ova are impregnated by different men very nearly at the same time. 



118 CONGENITAL AND INFANTILE MALFORMATIONS 

ture of the female sex. Sometimes these organs contain few if any 
follicles, and are incompetent to their duty in the economy. The results 
of this arrest of perfect development are amenorrhoea and sterility, 
which usually prove entirely rebellious to treatment. 

The activity with which this reduplication and formation of follicles 
goes on may be judged of by Sappey's 1 statement that Kblliker counted 
in a foetal ovary more than six thousand. 

Absence and Rudimentary State of Vagina. — Like the uterus, 
the vagina is created by union of the Mullerian ducts, and like it also 
is subject to a variety of malformations, due to an arrest of develop- 
ment or failure of complete union. The chief of the anomalies thus 
created are diminutive, rudimentary, unilateral, and atresic vaginae. 
Some of these are productive of no evil consequences and require no 
treatment ; others will be considered under the heads of Atresia Vaginae 
and Retention of Menstrual Blood. 

iSho?*t Vagina. — The vagina may be congenitally so short as to 
afford scant room for the male organ during connection. Proportionally, 
the vaginal portion of the cervix is then short, and the vaginal vaults 
are so shallow as to materially alter the normal relations between the 
uterine and vaginal axes. 

Anomalies of Uterine Development during Childbirth. — The uterus 
is an organ which varies greatly at different periods of life in size and 
shape. In the foetus, the girl at puberty, the nulliparous woman, the 
multiparous, and the old woman who has lived beyond the menopause 
it is a different organ in these respects. In the first the neck is dis- 
proportionately large ; in the second the body and neck gradually 
become equal in size ; in the third the size of the body preponderates ; 
in the fourth the cavity of the body enlarges and the os externum 
changes its shape ; and in the fifth a general physiological atrophy 
occurs, which diminishes the size of the whole uterus, though affecting 
the body somewhat more than the neck. 

It is the changes, and the anomalies which mark them, occurring 
between birth and the establishment of puberty which are now to 
receive attention. During this time the uterus very slightly develops 
until puberty is reached, when the rapid development of that period 
shows itself especially in this organ. During childhood the uterine 
body is bent forward, an anteflexion existing. This gradually passes 
off, leaving onky a slight ante-curvature, to last through life, as the 
changes of puberty cause the uterine walls to become dense and resistant. 
At puberty one wall sometimes develops rapidly, while the other cor- 
respondingly undergoes atrophy. Anteflexion, or more rarely retro- 
flexion, is the result, and the first menstrual effort is attended by pain 
and obstruction. Any influence which presses the abdominal viscera 
down upon the uterus while yet this organ is soft and yielding tends 
to develop this anomaly, which has received the name of congenital 
flexion. 

Again, the foetal uterus with its disproportionately long neck may 
disappear, and still the organ, now well proportioned, may not undergo 
development at puberty, but may remain small and unprepared for its 

1 Courty, Mai. de l' Uterus, p. 6Q. 



OF THE FEMALE SEXUAL ORGANS. 119 

coming functions. This constitutes the incompletely developed uterus of 
Kiwisch, Rokitansky, and Scanzoni, the pubescent uterus of Puesch, 
and the congenital atrophy of other writers. 

This condition is marked by tardy occurrence of menstruation and 
by a feeble, irregular, and scanty discharge ; a marked tendency to com- 
plete amenorrhoea existing. 

Fortunately, a good deal of benefit, under these circumstances, often 
results from treatment calculated to attract nervous influence and nutri- 
tion to the defective organ. The most reliable of these are the cautious 
and systematic use of small tents, the employment of an intra-uterine 
galvanic stem, a current of electricity passed through uterus and ovaries, 
and the complete establishment of the general health by exercise and 
tonic treatment. 

In some of these cases the most unfortunate results show themselves 
in connection with the nervous system. In several cases we have seen 
epilepsy, and in one mental imbecility, which seemed to be clearly 
traceable to the absence of sexual development. 

Even when no general symptoms show themselves, the undeveloped 
condition which characterizes these cases to a certain extent incapaci- 
tates the female for the duties of wife and mother. 



Hermaphrodism. 

By this term is meant a congenital malformation of the sexual organs 
in which the germinal gland of each sex (the testicle in the male and 
the ovary in the female) is found in one and the same individual, together 
with more or less perfect organs belonging to both sexes. Anatomically 
and clinically, hermaphrodism may be divided into two chief varieties — 
the true and the false or pseudo hermaphrodism. 

Of true hermaphrodism there may be three forms : first, the bilat- 
eral, in which an ovary and a testicle are found on each side ; second, 
unilateral hermaphrodism, when an ovary or a testicle is found on one 
side and on the other • both ovary and testicle — no well-authenticated 
case of this variety has been recorded ; third, lateral hermaphrodism, 
with an ovary on one side and a testicle on the other. A number of 
examples of this class have been reported, the best known of which is 
probably that of Katharine Hohmann, in whom we had an opportunity 
to satisfy ourselves by repeated thorough examinations that, besides two 
testicular- shaped bodies in the folds of skin on either side of the vaginal 
pouch, there was a small rudimentary uterus to be reached by the sound 
through the hypospadiac urethra, and to the left a body which could be 
taken for nothing else than an ovary. In the year 1867, in Scanzoni's 
clinic at Wiirzburg, we had occasion to carefully observe this individual 
during several months, and repeatedly saw a discharge of blood oozing 
from her urethra at four-weekly intervals, which could properly be 
taken for normal menstrual blood. During the same interval we had 
the opportunity, too, to examine fluid ejaculated from the urethra which 
showed the presence of spermatozoa. At this time the person posed as 
a woman. In 1875 the same person called on us in New York in the 
garb of a man who was then fifty-one years of ago. informed us that he 



120 CONGENITAL AND INFANTILE MALFORMATIONS 

Fro. 42. 




Front View of Genital Organs of Katharine Hohmann. 
Fro. 43. 




Same, more from the front, a Stylet introduced into the Opening of the Urethra. 



OF THE FEMALE SEXUAL ORGANS. 



121 



had passed the menopause successfully, and since then had assumed the 
functions of a man and was married to a woman. At our solicitation 
he allowed us to be present during the act of sexual intercourse, and we 
distinctly saw and smelled the semen on the genital organs of his wife. 



Fir. 44. 



Fig. 41 





Upper Half of Anterior Surface, showing the 
breasts (Katharine Hohmann). 



Posterior Surface, showing the long hair, 
the slender back, tbe broad hips, and the 
finer build of the left side (Katharine 
Hohrnann). 



Unfortunately, a post-mortem has never been held upon this person, 
supposing him to be now dead, by which the examinations during life 
could be verified. 1 

According to this case, an individual possessing the attributes of the 
true hermaphrodite might be expected to be able to fulfil the sexual 
functions of either sex at will. 

False Hermaphrodism. — By far the majority of cases of so-called 
hermaphrodism which come to the notice of the practitioner are those 
in which the individual is really of one sex, some of the peculiarities 
of the genital organs of the other sex being present in a sufficient 
degree to mislead a careless observer. There are two great varieties 
of this malformation : 

First, Androgyne, in which a man simulates a woman both in the 
general conformation and in the local appearance of his sexual organs. 
The face is usually more or less beardless; the hair is likely to grow 
long; the breasts are well developed, with prominent nipples and areo- 
lae ; the hips are perhaps a little broader than in normal man, still not 

1 See Munde: "A Case of True Lateral Hermaphrodism," Amer. Jown. of Obstetrics^ 

1875. 



122 CONGENITAL AND INFANTILE MALFORMATIONS 

so wide as in a well-formed woman. The thighs are round and more 
muscular than in woman, the voice is rough, and the larynx prominent. 
In the sexual organs the mons veneris is covered with the usual amount 
of hair ; the penis is about half the size and length of that of a normal 
man; the urethra ends, not at the tip of the glans, but either halfway 
down the lower surface of the organ or at its very root (hypospadias) ; 
the scrotum is cleft into two fleshy folds simulating the labia majora, 
each of which contains a testicular-shaped body with epididymis, or one 
of the testicles may be still in the inguinal canal or even in the abdom- 
inal cavity. Between these labia there is a blind pouch varying from 
half an inch to three inches in depth. A bimanual rectal examination 
of course reveals the absence of the internal sexual organs of a female. 
The diagnosis is easily made by a correct appreciation of the above signs. 
This is by far the most common variety of spurious hermaphrodism. 
Usually the penis is capable of erection, and ejaculation- of semen takes 
place from the hypospadiac urethra ; therefore impregnation of a female 
could take place if it were possible so to approximate the male and female 
organs as to introduce the semen into the vagina. Such individuals 
have, on the other hand, been looked upon as women, married as such, 
and their true sex has never been discovered until inquiry was made of 
some physician as to the reason of their not conceiving or the post-mor- 
tem has revealed the true state of affairs. 

There are several cases on record, one of which we think we have 
observed, 1 where the external genital organs were those of a perfectly 
formed female, but where the vagina was a blind pouch of nearly normal 
depth. Uterus and ovaries were absent, but in each labium was to be 
felt a body shaped like a testicle, with an apparent epididymis. Menstru- 
ation and molimina had never been present. In a similar case of 
Leopold the post-mortem verified the fact that the labial bodies were 
testicles. 2 

[It is due Dr. Thomas to state that he differed from me in his view of 
this case, believing the labial bodies to be prolapsed ovaries. — P. F. M.] 

Second, G-ynandria, the far-less frequent condition in which a 
woman simulates a man, the resemblance being confined almost entirely 
to the external sexual organs. The clitoris is elongated two to three 
inches and possessed of more or less erectility. (See Fig. 48.) Of course 
only a very superficial examination would mislead an expert into taking 
such a woman for a man. 

The treatment of hermaphrodism is practically nil. A hypospadiac 
urethra may possibly be restored to its normal condition by a plastic 
operation, or a blind vaginal pouch closed, but usually nothing can be 
done to restore the parts to their normal state. A hypertrophied clito- 
ris should, of course, be removed. 

1 See case of Munde, article by Swasey, Amer. Journ. Obst., vol. xiv., 1881. 

2 Swasey, loc. tit. 



DISEASES OF THE VULVA. 



123 



CHAPTER VIII 



DISEASES OF THE VULVA. 



Normal and Applied Anatomy. — The vulva is the name given 
to the external genitals, comprising the mons veneris, labia majora 
and minora, clitoris, meatus urinarius, vestibule, fossa navicularis, four- 
chette, and hymen. 

Labia Majora. — From the mons veneris, which consists of adi- 
pose tissue covered by skin in which exist numerous hair-bulbs, two 

Fig. 46. 




Vulva of Virgin. 



folds of integument pass downward to unite at the fourchette. These 
are called the labia majora. Externally they are covered by skin 
which contains scattered hair-bulbs, but on their inner surfaces their 
covering is mucous membrane, which is studded with sebaceous folli- 



124 



DISEASES OF THE VULVA. 



cles, the secretion of which is unctuous and semisolid. These glands 
are remarkably large, reaching, according to E. Klein, 1 a diameter of 
0.5 millimetre. They open immediately upon the free surface. 

Within, the labia are filled with adipose tissue, a portion of which 
is enclosed in sacs, of which one arises from each external abdominal 
ring and extends downward toward the fourchette. To these Broca 
has given the name of dartoid sacs. The peculiar anatomical confor- 
mation of the labia majora is intended to allow their expansion durino- 
expulsion of the foetus at term. After labor the distended and flabby 
labia rapidly contract to the condition previous to pregnancy. 

The Clitoris. — Beneath the superior commissure of the labia juts 
forward a little erectile organ, which is analogous to the penis of the 
male and receives the name of clitoris. It is covered by mucous mem- 
brane, consists of erectile tissue, and arises by two rami, one of which 
is attached to each ramus of the pubes. Like the penis, this little 



Fig. 4< 



. ■ 






WesMJMl^W^k 


.. \i y. ■■ '' ..\ S* 


ffixBKB&m* 


- * ". 






i'.&Sje^ ; >';', 


' 




'»*»','> 


'.'v;V :,■'■;• ■•.-;, 


''"'? "" ' Wi' ; . 




• 








;f\ m. 




••4 °& 








§'*'' f 












•'" t ' J» ■?? i% • 




/- .^A%L ''"- 


r ^*tf0 :; 


*w mm 


I 


• 


*M&f*~. 















Vulva of Married Nullipara. 

organ is provided with a prepuce and frcenum. The object of the 
clitoris is to furnish to the female the nervous erethism which is neces- 
sary to a perfect performance and completion of the sexual act. In 
fact, it may be said to be the organ of voluptuousness in the female, by 

1 Strieker's Manual of Histology. 



DISEASES OF THE VULVA. 125 

the excitement of which, outside of the sexual act, an orgasm and 
ejaculation of mucus from the Bartholinian glands is produced. 

Labia Minora. — These consist of two folds which, arising at the 
clitoris, pass downward and disappear about halfway between the two 
commissures. Like the clitoris, they are formed of erectile tissue cov- 
ered over by mucous membrane, and an attentive examination dis- 
covers upon their surfaces a large number of glands which secrete a 
sebaceous material. These organs also take part in furnishing suffi- 
cient tissue for distension during parturition. In certain races, nota- 
bly the Hottentot and other African negroes, the nymphse normally 
attain a length never met with except as a disease in Caucasian races, 
sometimes extending downward nearly to the knees, and being looked 
upon as signs of distinction by their possessors. 

The Fossa Navicularis and Vestibule are merely spaces interven- 
ing — the first, between the perineum and vagina ; the second, between 
the meatus and clitoris. They are both covered by mucous membrane, 
and the latter is studded with follicles. 

The fossa navicularis becomes distinct only on separating the labia, 
whereby the posterior commissure is put on the stretch ; a boat-shaped 
furrow is thus formed between the hymen and the fold of skin called 
the posterior commissure. The vestibule, on the other hand, is un- 
changed in shape or appearance whether the labia are separated or not, 
being situated between the two unyielding branches of the pubic bones. 
The posterior commissure is usually torn during the first confinement, 
such a tear being considered almost physiological and requiring no 
treatment. 

The Hymen is a thin veil consisting of a double fold of mucous 
membrane, which in part closes the ostium vaginae. When ruptured 
its remains can be distinctly discovered, sometimes not at all diminished 
in bulk, at the orifice of the vagina. 

These remains are called the carunculae myrtiformes, from a fancied 
resemblance to the buds of the myrtle as seen by the old anatomists. 
The hymen is usually ruptured by the first sexual intercourse, but its 
remains are visible in the shape of the caruncles just mentioned. 
When these caruncles are entirely absent or exist only on the anterior 
segment of the vaginal orifice, as is most frequently the case, they 
have either been destroyed by the distension and inevitable superficial 
sloughing following parturition at term, or by the passage of some large 
body, such as a fibroid tumor, over the perineum, or the hymen is 
congenitally absent. The knowledge of the different conditions of the 
hymen and its remains is of importance from a medico-legal standpoint, 
since often the physician is called upon to decide whether a woman is a 
virgin, has had connection, or has borne children, and only a physical 
examination can decide the question correctly, 

Passing over the clitoris, to which it is attached, and running down- 
ward on each side of the vulva, so as in part to cover the bulbi vesti- 
buli, will be found a muscle which is, we think, very generally regarded 
as the sphincter vagime. Savage 1 denies that it, the bulbo-cavernous 
muscle, has any such influence, the true sphincter vaginae being the 
1 Female Pelvic Organs, 3d ed. 



126 



DISEASES OF THE VULVA. 



pubo-coccygeus muscle, which is seen, by dissection within the pelvis, 
arising from the inner surface of the pubic bones. Descending on the 
sides of the vagina, some of its fibres pass between it and the rectum 
to meet others from the opposite side in the perineum. Another set go 
behind the rectum, and, uniting with similar ones from the opposite side, 
intermix with its circular fibres to make the internal sphincter. The 
remaining fibres, still more outward, are inserted in the sides of the 
coccyx. 

Deformities of the Vulva. 

Hypertrophy of the labia majora and of the nymphoe is not of uncom- 
mon occurrence. It may be caused either by syphilitic infection, 
elephantiasis, inflammatory hyperplasia, or by the irritation set up by 
the practice of masturbation. 

Hypertrophy of the clitoris may occur in consequence of the same 
causes, and is more apt to be found in prostitutes. All three of these 
diseases are more common in tropical climates, owing to the irritation 
produced by the decomposition of the natural secretion of the parts by 
the heat. Enlargement of the clitoris is by no means as frequent in 
our experience as in that of other writers whose opportunities for examin- 

Fig. 48. 




Hypertrophy of Clitoris (Tait). 

ing women subject to the peculiar causes of this disease have been 
greater than ours. 

The treatment consists in the removal by the knife of any of these 
organs which may by its size cause inconvenience to its possessor. 
Hemorrhage, which may be severe, should be controlled by passing 
deep pins underneath the mass to be removed, tying an elastic ligature 



NEOPLASMS OF THE VULVA. 1<}7 

around the mass under the pins, and then, after removing the mass, 
inserting deep sutures, which can be readily tied as the pins are with- 
drawn, and thus all bleeding be avoided ; or the galvano-cautery loop 
or the Paquelin cautery may be employed. Removal of the clitoris, 
unless decidedly enlarged, is very seldom required. The excision of 
the normal organ for the cure of masturbation, nymphomania, or general 
neurosis, which many years ago was introduced by Baker Brown of 
London, has long since fallen into disuse. We have never performed 
it. Unless the nymphae are very much enlarged, so as to incommode 
the patient or interfere with coition, they should not be removed. 

Atrophy of the Labia, Nympha?, and Clitoris. — Occasionally all 
these organs may be congenitally absent or so imperfectly developed as 
to be scarcely perceptible. After the menopause, as old age approaches, 
the physiological senile atrophy of these organs takes place, which 
change occurs equally in the internal sexual organs. No treatment is 
required, or indeed would be effectual, for this atrophy. 

Neoplasms of the Vulva. 

Besides the deformities of the vulva described in the previous sec- 
tion, this part is subject to the formation of a variety of tumors, the 
chief of which are condylomata, acuminated and flat, papillomata, fibro- 
mata, cysts, myxomata, lipomata, elephantiasis, lupus, sarcoma, cancer, 
osteomata, enchondromata, neuromata, and hydrocele. 

The condylomata acuminata or papillomata may be due to gonorrhceal 
irritation, or simply to the hyperemia and discharge from the parts occur- 
ring during a vulvo-vaginitis or a normal pregnancy. They are found 
chiefly on the labia minora at the posterior commissure, and may extend 
more or less deeply into the vagina. The condylomata lata occur 
usually on the inside of the labia majora or on the perineum and around 
the anus. They are always due to true syphilitic infection. 

The treatment of the acuminate or papillomatous growths (so-called 
venereal warts) consists chiefly in removing them with scissors and 
touching the wounds with the stick of nitrate of silver or strong nitric 
acid. Compresses soaked in the tincture of Thuja occidentalism mixed 
with equal parts of water, are said by Piffard to cause atrophy of these 
growths. The broad condylomata are of course treated on the anti- 
syphilitic plan. 

Fibromata of the vulva are of uncommon occurrence, and are 
usually found in the labia majora, as is also the case with cysts, myxo- 
mata, and lipomata. The differential diagnosis of these various growths 
is made on general principles, care being taken always by percussion to 
eliminate the possibility of a labial hernia being mistaken for one of 
these tumors. None of these growths, as a rule, attains a very large 
size, except the lipoma, which has been observed reaching almost down 
to the knees, in one case weighing ten pounds. The cysts seldom grow 
larger than a hen's egg; the fibromata have been found the size oi' a 
child's head. 

The treatment, of course, consists in removing them — that is. dis- 
secting them out with the knife — and closing the wound by deep sutures. 



128 



DISEASES OF THE VULVA. 



Elephantiasis of the vulva usually affects the clitoris, the labia 
majora, and nyraphse all together, and may grow to such size as to com- 
pletely close the vaginal orifice and interfere with coition. (In one 
case, a colored woman four months pregnant, whom I saw several 
years ago, I was obliged to remove the mass, which involved all the 
organs mentioned, because its increase of growth during pregnancy 
would have inevitably prevented the delivery of the child. The woman 
recovered without difficulty and carried her child to term. — P. F. M.) 

Fig. 49. 




Elephantiasis of Vulva (Munde). 

Lupus, sarcoma, and cancer are fortunately rare. They occur usually 
upon the labia minora or majora, spreading thence in various directions; 
and we have seen the whole mons veneris a raw bleeding sore from 
epithelioma and lupus respectively. 

The prognosis of cancer, which is usually of the epitheliomatous 
variety, is, of course unfavorable unless seen sufficiently early to allow 
of complete extirpation. Lupus is more readily cured. Sarcoma pre- 
sents itself as a tumor springing from either the labia majora, minora, 
or clitoris, and is diagnosed mainly by its rapid growth and soft feel. 
After removal of course the microscope settles the diagnosis. If it can 
be completely removed, the prognosis is favorable, otherwise it is liable 
to return very soon. 



VUL VITIS. 1 29 

Osteoma and enchondroma of the vulva are reported by some of 
the older observers, but no recent writer mentions any well-authen- 
ticated case of these (in this region certainly unexpected) neoplasms. 

Neuromata of the vulva, however, are of more frequent occur- 
rence, and are either situated about the meatus urinarius or clitoris 
or at the posterior commissure, where they spring from the torn rem- 
nants of the hymen. These neuromata are usually nodules not larger 
than a pea or bean and exquisitely sensitive to the touch, causing pain 
not only during walking and other accidental friction, but also during 
coition. They should be removed by thorough deep excision with 
scissors. 

Hydrocele will be referred to in a separate section later on in this 
chapter. 

Vulvitis. 

Definition. — Vulvitis is the name applied to inflammation of the 
skin and mucous membrane covering the vulva. Affecting all of these 
structures, the surface covered hv epithelium and the glands imbedded 
in it, the inflammatory action sometimes extends through the submucous 
tissue into the proper structure of the parts underlying it, creating 
tumefaction, pain, and sometimes even suppuration. 

Varieties. — Authorities differ with regard to the classification of its 
varieties. 

That which appears most appropriate is the following : 
Simple vulvitis ; 
Purulent vulvitis ; 
Follicular vulvitis. 

There is a variety of the affection also which is styled gangrenous, 
but it is so entirely confined to children that its consideration here 
would be out of place. 

Simple Vulvitis 

is by far the most common form of inflammation of the vulva. It is 
usually produced by the irritation of an acrid and irritating vaginal 
discharge, by the presence of pediculi pubis or of pruritus ; the irrita- 
tion induced by the original cause being aggravated very greatly by the 
rubbing and scratching of the patient in her efforts to allay the burning 
and itching. The secretions from the inflamed surfaces are usually of a 
serous, non-purulent character ; they are not infectious, except where 
possibly a gonorrhoeal virus may have caused the disease. The dia- 
gnosis is made by the red, eroded appearance of the vulva, which appear- 
ance often extends down to the anus and to both nates, especially in fat 
women. In blondes the secretion of the vagina and vulva decomposes 
more readily than in brunettes, hence the mucous membrane and skin 
are more acutely inflamed and eroded in the former. 

The treatment consists in removing the original causes — namely, the 
irritating vaginal discharge — or in destroying the lice, with ungt, 
hvdrargyri or ungt. sabadillre or, if examination of the urine shows 
the presence of sugar, endeavoring to cure this source of irritation by 

9 



130 DISEASES OF THE VULVA. 

proper dietetic regimen. Locally, the application of a solution of 
nitrate of silver of twenty grains to the ounce every other day, with fre- 
quent lotions of the lead-and-opium wash diluted one to eight, or used 
in the same strength on cloths worn over the vulva, will very soon pro- 
duce great improvement, and, if persevered in, a cure. Also daily 
tepid sitz-baths will be found to afford much relief from the itching. 
This form of vulvitis may, if of a severe type or allowed to run on 
unchecked, merge gradually into the next variety, or purulent vulvitis. 



Purulent Vulvitis. 

This variety of the affection may be either of non-specific form or a 
true gonorrhoea of the vulva. The former is in many respects anal- 
ogous to balanitis in the male, while the latter resembles very closely 
specific inflammation in other mucous membranes of the body. 
Causes. — It may result from 

Simple vulvitis ; 

Vaginitis, specific or simple ; 

Want of cleanliness ; 

Injury, or friction from exercise; 

Eruptive disorders ; 

Onanism ; 

Chemical irritants ; 

Excessive venery. 
Symptoms. — The parts are red, swollen, hot, and at first dry. Then 
a free flow of pus takes place which bathes the whole surface and stains 
the linen of a yellow hue. In addition to these signs of active inflam- 
mation, superficial ulcers will be found scattered over the parts affected, 
and in rare cases patches of diphtheritic membrane will be seen adhering 
to them. At times the meatus urinarius becomes affected, and painful 
micturition, with scalding and heat, is complained of. At others the 
most intense pruritus affects the vulva, and the patient in endeavoring 
to obtain relief may contract the habit of masturbation. Should the 
inflammation extend to the vagina, the symptoms of vaginitis will also 
show themselves, and by a similar extension to the bladder those of 
cystitis may develop. In severe cases febrile action, with thirst, heat 
of skin, and general discomfort, is present, but this is not usually the 
case. 

The pus which is discharged, ahvays in the specific form of the dis- 
ease and very generally in the non-specific, gives forth a disagreeable 
odor, and is usually so irritating in its nature as to excoriate the inner 
surfaces of the thighs when it comes in contact with them. Should this 
material, even in the non-specific form of the affection, be carelessly 
brought in contact with the conjunctiva, a severe form of purulent 
ophthalmia is excited. No doubt an acute urethritis may be induced 
in the male by contact with this discharge, although no suspicion what- 
ever of a venereal affection exists in either party. This urethritis will 
be much more amenable to treatment than gonorrhoea, or may even 
cure itself. The secretions of both male and female are found to be 



VULVITIS. 131 

free from the germ now universally considered pathognomonic of gonor- 
rhoea — namely, the gonococcus. 

Course and Termination. — Even without treatment it is probable 
that the affection would always be recovered from in time; but it would 
run a lengthy and tedious course, and perhaps give rise to complica- 
tions which would be productive of greater evil than the original 
disorder. When properly treated it generally runs a rapid course and 
is readily cured. 

Treatment. — If inflammatory action be excessive, the patient should 
be kept in bed upon low diet, and the bowels freely acted upon by 
saline cathartics. Emollient applications should be made constantly 
to the inflamed part, and cleanliness scrupulously observed. The 
patient should be directed to bathe the vulva freely with warm water 
three or four times daily, and to apply a warm poultice of powdered 
linseed, slippery elm, or grated potato. To the poultices may be added 
with advantage a solution of acetate of lead and tincture or powder of 
opium. 

As soon as the acute action has subsided, the lead-and-opium wash 
already referred to should be kept in contact with the parts by dossils 
of lint soaked in it and placed between the labia. It is thus com- 
pounded : 

fy Tr. opii, gij ; 

Plumbi acetat., 3j ; 

Aquae, Oj. — M. 

At a still later period the diseased surface should be painted over sev- 
eral times a day with a solution of persulphate of iron and glycerin, 
1 part of the former to 8 of the latter. Should the disorder not be 
entirely eradicated by this treatment, the vulva may be painted over 
once in every forty-eight hours with a solution of nitrate of silver, 10 
grains to the ounce of water, and kept constantly powdered with lyco- 
podium, bismuth, or starch until recovery is complete. Should pruritus 
attend the latter stages of the disorder, a wash composed of 1 scruple 
of carbolic acid to 1 pint of water will be found useful. 

In many obstinate cases the painting of the vulva with a solution 
of 1 : 2000 of corrosive sublimate, followed by the application of a 
10 per cent, ointment of cocaine, with lanolin, will give great relief 
and hasten the cure. The application of solution of nitrate of silver, 
followed by the lead-and-opium wash, has on the whole given us the 
best results. 

Adhesive Vulvitis. 

By this term we mean to imply the adhesion and eventual firm union 
between the nymphre, and even the labia majora, in cases of acute or 
subacute vulvitis where the disease has caused the adjacent surfaces to 
become eroded. This accident is not so likely to occur in married 
women, for obvious reasons, as in women whose genital organs are not 
subject to frequent physical disturbance. In young children, virgins, 
and in women whose organs are undergoing senile atrophy, however, we 



132 DISEASES OF THE VULVA. 

have seen the adjacent surfaces of the labia so firmly united as to require 
division by the knife. Recently a child of two vears was brought to 
us by her physician, because the mother had noticed that below the 
meatus urinarius the vaginal orifice seemed closed. On sharply pull- 
ing apart the labia with the fingers, they parted, revealing the normal 
entrance of the vagina. The raw surfaces of the labia were painted 
with a mild solution of nitrate of silver and ordered to be kept apart 
by pledgets of lint until healed. In a nulliparous married woman who 
recently came under our care for painful coition we found the cause of 
this complaint to be a firm union of the nynrphae down to the level of 
the meatus urinarius. The insertion of the penis of course stretched 
this apron of skin transversely and gave rise to severe pain. There 
was no history of vulvitis, but undoubtedly this must have been pres- 
ent, as the pain was of comparatively recent date. We excised a wedge- 
shaped strip from the median line of the adherent surfaces as far up as 
the clitoris, and sewed the lateral edges of the wounds together, and 
then kept the vaginal orifice open by the daily use of dilators, with the 
result of a perfect cure (P. F. M.). 

Follicular Vulvitis. 

Definition and Synonyms. — It has been already stated that in the 
mucous membrane lining the vulva, more especially in that covering 
the labia majora, labia minora, and vestibule, numerous follicles exist. 
Presenting themselves as solitary glands, they are classified under the 
three following heads : muciparous, sebaceous, and piliferous. In ordi- 
nary purulent vulvitis these, as component parts of the diseased mem- 
brane, are implicated in the morbid action. Sometimes, however, they 
alone are affected by disease, when the name of follicular vulvitis or 
vulvar folliculitis has been applied to the condition. Any or all of 
the varieties of glands just mentioned may be diseased, and authors 
have given special names to the varieties, so that a list which would 
comprise them all would be a long one. As examples may be men- 
tioned papillary, pruriginous, erythematous, sebaceous, granular vul- 
vitis, etc. 

We may avoid tediousness of detail, and at the same time run no 
risk of being led into error, by classing all forms of inflammation affect- 
ing the solitary glands of the vulva under the head of follicular vulvi- 
tis ; provided that we bear in mind that all the varieties of glands may 
be simultaneously affected, or that one set alone may be diseased, the 
others remaining healthy. 

Causes. — This form of vulvitis may be induced by the following 
influences : 

Pregnancy ; 

Neglect of cleanliness ; 

Vaginitis ; 

Exanthemata ; 

Eruptions on the vulva. 

Symptoms. — There are burning, itching, and heat in the vulva, with 



VUL VITIS. 



Fig. 50. 




Follicular Vulvitis. 



increase of glandular secretion. At times the secretion is excessively 
offensive and irritating in cha- 
racter. The urethra frequently 
becomes inflamed at its vulvar 
extremity, and scalding in the 
passage of urine results. The 
vulva may become so sensitive 
to touch that efforts at sexual 
intercourse excite vaginismus, 
which thus constitutes a symp- 
tom of the disease. 

Physical Signs. — If the mu- 
ciparous follicles be chiefly affect- 
ed, the mucous membrane of the 
vulva will be found intensely red 
in spots or patches which are 
slightly elevated. These are most 
commonly found on the edges of 
the lower vaginal rugae, the nym- 
phse, and the carunculae. They 
sometimes resemble the swollen 
villi upon the tongue, and bleed 
upon slight irritation. 

Should the disease have affect- 
ed chiefly the sebaceous and pilif- 
erous glands, little, red, rounded 

papillae will be found on the surfaces of the labia majora and minora 
and the base of the prepuce of the clitoris. After a while a drop of 
pus will appear in the apex of each, which is soon discharged and the 
distended follicle shrivels. Beneath the labia minora a semifluid mass 
of offensive secretion will generally be found, which will, if not care- 
fully removed, conceal the follicles underlying it. 

Course and Duration. — If this disorder occur during pregnancy, it 
may disappear at its conclusion. In some cases it becomes so severe 
and produces such annoying symptoms that abortion is induced by it. 
If it exist in the non-pregnant state and be not appropriately treated, 
it may continue for an unlimited time and establish urethritis, not only 
in the patient, but in her husband. This fact should be especially recol- 
lected, for a suspicion of want of chastity may be excited in the mind 
of the husband, and serious domestic difficulty result. 

Treatment. —Follicular vulvitis should be treated upon the same 
principles as the purulent form — by repeated ablution, warm poultices, 
sedative washes, and local alteratives, especially the persulphate of iron 
and nitrate, of silver. In case these remedies do not give relief in the 
course of a few days, the inflamed and enlarged follicles, especially if 
they contain pus, must be punctured with a sharp, slender knife, and 
their bases thoroughly incised, so as to destroy the follicle. The con- 
tents then having been gently squeezed out, flaxseed poultices should 
be applied until all inflammatory action has subsided, am! then the 
wounds healed by the ordinary wet, 2 per cent, carbolized dressing 



134 DISEASES OF THE VULVA. 

now in vogue in our surgical wards. It is rare that a ease of this dis- 
ease resists treatment of this kind for any definite period. A few very 
exceptional instances are on record where the diseased skin had to be 
dissected off in order to effect a cure, the sound edges of the wound 
being at once united by sutures. 



Eruptive Diseases of the Vulva. 

The skin and mucous membrane making up the vulva mav. like 
the same structures in other parts of the body, be affected by erup- 
tive disorders of various kinds. It is not our intention to enter with 
any minuteness into the consideration of these diseases, for which we 
refer the reader to any of the modern works upon derniatolosv. but 
merely to note the fact that they may occur upon this part, and men- 
tion the leading characteristics of the most frequent of them. 

Any eruptive disorder which may elsewhere affect the skin or mu- 
cous membrane of the body may show itself on the vulva. The fol- 
lowing list includes those which are most commonly meT wiTh and 
most frequently call for diagnosis and treatment : 

Prurigo and lichen : 

Eczema : kraurosis vulvae (^Breisky) : 

Acne ; 

Elephantiasis : 

EryThema and erysipelas : 

Syphilides. 
As is The case elsewhere with prurigo. ThaT of The vulva presenTs 
large, scattered papules, very irritating, and generally having Their 
apices bereft of cuticle. Eichen shows more numerous papules, which 
rest upon a thickened and somewhat indurated cutaneous base. Pru- 
ritus vulvae is the most prominent symptom of these maladies. So 
intense is the irritation of the vulva established by them that vul- 
vitis is the consequence, the disease then being styled pruriginous 
vulvitis. 

In eczema the surface is red. heated, and covered by little vesicles, 
which, breaking, give forth a serous fluid. The eruption confines 
itself chiefly to the cutaneous surface, the mucous lining being less 
affected. It may pass off' rapidly as an acute disorder, but sometimes 
there are successive crops of vesicles which exhaust the strength of the 
patient in consequence of the nervous excitement and irritability 
which the disease induces. In many cases of diabetes and vesicovagi- 
nal fistula this affection constitutes an exceedingly annoying and even 
painful complication. 

The late Prof. Breisky of Vienna described a few years ago a pecu- 
liar disease of the vulva to which he gave the name of kraurosis 
(xpauooc. "shrunken." "dry"), the peculiarity of which was that the 
skin of the labia and mucous membrane of the labia majora and nymphae 
and of the vestibule, as well of the outer surface of the hymen, became 
glistening white, tense, and contracted. The chief symptoms complained 
A by the patient were severe paroxysms of pain at irregular intervals 
in the affected parts. No specific history, and usually not even The 



PHLEGMONOUS INFLAMMATION OF THE LABIA MAJOR A. 135 

history of chronic ecEema, could be obtained from the patients. The 
disease affected both virgins and married women. (We ourselves have 
seen such a case in a virgin of thirty-six who was referred to us by 
Prof. Breisky himself. All the ordinary treatment was ineffectual, 
and we consulted Dr. Charles Heitzmann, who pronounced it to be a 
case of chronic eczema, and recommended the use of the sharp curette 
and the painting of the surface with a saturated solution of salicylic 
acid in alcohol, by which the patient was, after a long and tedious pro- 
cess, entirely cured, the latter part of the treatment being under the 
direction of Dr. Heitzmann. — P. F. M.) 

Acne consists in engorgement of the sebaceous follicles studding 
the labial faces — not in active inflammation, which would bring the 
case under the head of follicular vulvitis, but in engorgement by their 
own retained secretion. 

Elephantiasis of the labia differs in nothing from that of other 
parts. The affection is very rare. Kiwisch records one case in which 
both labia increased in size, so as to equal the head of a man and to 
fall nearly to the knees. The parts affected by it are the labia majora 
and minora, the clitoris, and the perineum. 

Erythema and erysipelas are simply accompanied by graver symp- 
toms when they affect the genital organs than when they develop on 
the skin elsewhere. 

Syphilis in secondary and tertiary form may affect the labia, 
creating hypertrophy, ulceration, and all the evils which it excites in 
other parts. 

These disorders create the ordinary symptoms of vulvitis, and hence 
they are commonly confounded with it. Pruritus vulvae is one of their 
most constant signs, and the itching which it produces often first 
attracts attention to their presence. 

Treatment. — Little need be said here of treatment, for it should be 
guided by the rules which govern the management of the same cuta- 
neous disorders in other parts of the body. The general health should 
be carefully attended to ; change of air advised ; and tonics and altera- 
tives, such as iron and arsenic, prescribed in combination — the first 
with Colombo, or the second with the tinctures of cinchona or gentian. 
Local treatment should consist in the maintenance of strict cleanliness 
by bathing the diseased parts freely in tepid water, and the pruritus, 
which invariably exists and leads to scratching, should be relieved by 
lotions containing acetate of lead, opium, borax, or a small amount of 
creasote or carbolic acid. 

For eczema, keeping the affected parts constantly covered with strips 
of English lint spread with diachylon plaster, according to the method 
of Hebra, thoroughly scrubbing them before each application with green 
soap, has in our hands afforded us the most benefit. 

Phlegmonous Inflammation of the Labia Majora. 

The areolar and adipose tissues which in groat degree make up the 
bulk of the labia majora are very frequently the seat of inflammation 
and abscess. The disease is excited bv irritating: vaginal secretions, 



136 DISEASES OF THE VULVA. 

vulvitis, direct injury, and the peculiar blood-state which results in the 
development of furuncles and carbuncles. 

Symptoms. — In the first stage there is active congestion, which in 
the second produces hardness and tension from effusion of liquor san- 
guinis into the areolar tissue. The third stage consists in the breaking 
down of this mass by the process of suppuration and formation of an 
abscess. The pus which is thus created is usually very offensive from 
propinquity to the rectum and vulva. 

The Diagnosis is generally very easy. Attention is directed to the 
part by heat, pain, throbbing, difficulty of locomotion, and exquisite 
sensitiveness upon pressure. Upon physical exploration one labium is 
found very much swollen and quite hard and tender. Although it is 
usually easy to distinguish this disease, care must always be taken to 
differentiate it from labial hernia, displacement of an ovary, pudendal 
hematocele, oedema labiorum, and vulvitis. As this point will engage 
our attention elsewhere, it requires no further mention here. 

Treatment. — The treatment should consist, in the first stage, in the 
application of cold and sedative lotions, low diet, saline cathartics, and 
perfect rest. One of the best local applications will be found to be the 
lead-and-opium wash. As the second stage advances the process of 
suppuration, which is now inevitable, should be encouraged by poultices, 
and as soon as pus is distinctly discoverable it should be evacuated by 
puncture. Early opening is advisable, because the tissues obstinately 
resist natural evacuation, and the accumulation may pass upward toward 
the abdominal ring through the dartoid sac. 

Rupture of the Bulbs of the Vestibule. 
Anatomy. — If an incision be made by a scalpel through the skin 

Fig. 51. 



Plexus of Veins of the Vestibule (Kobelt). 



and its subjacent adipose tissue around the vulva, and all the tissues 
making up that part be dissected off, a reticulated plexus of large veins 



PUDENDAL HEMORRHAGE. 137 

will be found beneath the labia, called the pars intermedia and bulbi 
vestibuli. These extensive channels for blood have been represented 
by Kobelt, as shown in Fig. 51. 

Any influence which causes a rupture of these vessels must produce 
one of two effects : if there be a corresponding rupture of the skin, a free 
hemorrhage will occur, known as pudendal hemorrhage ; if not, the 
blood pouring out into the areolar tissue surrounding the wounded 
plexus will soon form a coagulum, constituting a bloody tumor, which 
has received the name of thrombus or pudendal hematocele. 

Pudendal Hemorrhage. 

Especial attention was called to this condition by Sir James Simp- 
son, 1 who in 1850 recorded from his own experience and that of others 
a number of instances in which from a very slight rupture of one labium 
fatal hemorrhage took place. He declared that criminal cases had 
repeatedly occurred in Scotland in which women, both pregnant and 
non-pregnant, had suddenly died from pudendal hemorrhage arising 
from rupture of the bulbs of the vestibule. Suspicion of injury at the 
hands of the husbands or neighbors had been entertained in most or all 
of the instances referred to. 

The accident is a rare one. But two instances have come under our 
notice — one occurring in consequence of puncture of the labium by a 
stick, the woman falling in crossing a fence ; the other the result of a 
similar puncture by a piece of china from the breaking of a pot de 
chambre. Both these cases readily yielded to the recumbent posture 
and the application of cold and styptic compresses. A very interesting 
case, the details of which we cannot now find, was published some 
time ago in one of the journals of the day. A lady, standing upon a 
chair to mount a horse, slipped and fell, so as to cause the sharp extrem- 
ity of one of the upright pieces to puncture one labium. Bleeding was 
profuse, and so obstinate as to require several attempts at checking it 
before it was finally controlled. This was in the end accomplished by 
a tampon in the vagina and firm compression by a T bandage. 

Causes. — The great predisposing causes are pregnancy, varicose 
condition of the veins, and a large pelvic tumor. The exciting causes 
are — 

Great muscular efforts ; 2 
Blows rupturing the labium ; 
Incisions or punctures. 

Symptoms. — The hemorrhage that announces the accident will load to 
a physical exploration, which will at once reveal the nature of the lesion. 

Treatment. — The nature of the accident being once recognized, the 
control of the. flow will not usually be difficult. If it be nor effected 
by cold and astringents, such as ice, the persulphate of iron, or tannin. 
the vagina should be filled with a firm tampon of cotton, a folded towel 
applied as a compress over the vulva, and a T bandage made to press 

1 Obstet Works, vol. i. p. 277, Am. ed. 

2 Prof. Simpson records a case due to straining at stool. 



138 DISEASES OF THE VULVA. 

this forcibly against the body. Should this plan fail, the wound should 
be enlarged by incision and filled with pledgets of cotton saturated with 
solution of persulphate of iron ; then the tampon should be applied in 
the vagina and a compress carefully adjusted by means of a T bandage. 
It is difficult to conceive of any case occurring in the non-pregnant 
woman which could resist this method if effectually employed. 

Pudendal Hematocele. 

Definition and Synonyms. — The term thrombus, derived from the 
Greek dooafoco. k- I coagulate." and which is used synonymously with 
hematoma and sanguineous tumor, is that which is generally applied 
to this condition. We have preferred the appellation of pudendal 
hematocele, given to the disorder by Dr. A. H. McClintock, from its 
pointing out the similarity between it and pelvic hematocele, which 
resembles it in pathology, and because the term "thrombus" is now 
commonly applied to the coagulation of blood in a blood-vessel. 

A pudendal hematocele is a tumor formed by a mass of clotted blood 
effused into the tissue of one labium or the areolar tissue immediately 
surrounding the wall of the vagina. 

History. — This disease has been known since the time of Eueff of 
Zurich in 1554. and has long been recognized as occurring not only 
during its favorite time of pregnancy, but also in the non-pregnant 
condition. Velpeau records an instance of its occurrence in a girl of 
fourteen years. 

Pathology. — The pathology of this condition is similar to that of 
pudendal hemorrhage, which has just received notice, for both are 
results of rupture of the bulbs of the vestibule. In that which we are 
now considering the effused blood, instead of pouring away, collects in 
the tissue of one labium under the vagina, or even in the areolar tissue 
of the pelvis, and forms a coagulum. It bears to pudendal hemorrhage the 
same relation which a simple fracture bears to one of compound character. 

Rupture of a branch of the ischiatic or pudic artery may, during 
labor, likewise produce a bloody tumor, but this should not be treated 
of under the technical head of pudendal hematocele, for it would really 
constitute a case of subperitoneal hematocele. 

Mode of Development. — "When a large vessel has been injured a 
tumor, perhaps the size of an orange, is suddenly discovered at the 
vulva. At other times the tumor is quite small, not larger than a 
walnut. The extent of the laceration likewise governs the rapidity 
with which the tumor forms after the injury has been inflicted. In 
some instances a slight flow slowly continues until compression from the 
clot checks it. "When the accident occurs in the non-pregnant state, 
the amount of blood effused is generally less extensive than in preg- 
nancy, and is usually confined to the vulva. 

Causes. — The causes are similar to those of pudendal hemorrhage — 
namely : 

[Muscular efforts ; 

Blows injuring the labia : 

Punctures by small instruments. 



PUDENDAL HEMATOCELE. 139 

Symptoms. — The symptoms are usually a sense of discomfort, with 
pain and throbbing, and if the effusion reaches the urethra there is 
obstruction to urination. The patient or attendant will often first 
recognize the fact that something abnormal has occurred by the sense 
of touch, practised without a suspicion as to the nature of the real 
difficulty. 

Differentiation. — Care must be observed not to confound this affec- 
tion with 

Abscess of the labia ; 

Pudendal hernia ; 

Inflammation of vulvo-vaginal glands ; 

(Edema labiorum. 

The mere announcement of the possibility of error in diagnosis is 
all that is necessary, for the physical characteristics, mode of develop- 
ment, and rational signs of these affections are so different from those 
of pudendal hematocele that examination will always settle the point 
with certainty. 

Prognosis. — If the sanguineous collection be small, it will, especially 
in the non-pregnant state, generally disappear spontaneously. If, how- 
ever, it be large, and if the patient have recently been delivered, there 
are always two dangers to be apprehended. The lesser of these is 
hemorrhage ; the greater, purulent infection through the walls of the 
cyst or the formation of an extensive abscess, which may produce the 
same result. These may follow in the non-puerperal form of the affec- 
tion, but the danger of both is much less great than in the puerperal, 
where the vessels of the part are largely distended in consequence of 
excessive growth, and where the blood-state is one of hydrsemia and 
hyperinosis. 

Natural Course. — Should the tumor be left to itself, it may be 
absorbed in a short time and leave no trace ; in five or six days it may 
burst and discharge ; the clot may become encysted and remain indef- 
initely in the tissues ; or the irritation of the clot may create suppurative 
inflammation, and abscess of the labium be the consequence. 

Treatment. — Should the tumor be small and not excite much pain. 
a cooling lotion of lead and opium should be applied, the patient kept 
quiet, and evacuations of the bladder and rectum regulated in the hope 
that absorption will take place. As soon as evidences of phlegmonous 
inflammation around the tumor appear, suppuration and discharge should 
be encouraged by poultices. When the tumor is large and experiment 
has demonstrated that it will not undergo absorption, it is advisable to 
evacuate the blood-clot by incision. This should be done by means of 
a bistoury upon the mucous face of the labium majus, the patient being 
placed under the influence of an anaesthetic. After an incision has 
been made, one finger should be inserted and the clot turned out of its 
nidus. If hemorrhages ensue, the sac should be thoroughly washed 
out with a solution of bichloride of mercury, 1:2000, and tightly 
packed with iodoform gauze, which will check any possible subsequent 
hemorrhage. This dressing should be renewed every three or four 
days, or oftener if saturated, the cavity being carefully irrigated each 
time until it closes by granulation. 



140 DISEASES OF THE VULVA. 



Pudendal Hernia. 



Anatomy. — By some anatomists it is stated that the round ligaments 
of the uterus end in the mons veneris, but this view is incorrect. A 
more careful dissection traces them through the internal abdominal 
rings, along the inguinal canals, to the labia majora, where they are 
lost in the dartoid sacs, described by Broca as passing through these 
folds. The labia majora are unquestionably the analogues of the scro- 
tum of the male, and the round ligaments correspond to the spermatic 
cords. Into the inguinal canals these ligaments are attended by a 
prolongation of peritoneum which has received the name of the canal 
of Xuck. This ordinarily becomes obliterated at full term of fcetal 
life, but not always. AVhen it remains pervious the formation of 
inguinal hernia is favored. 

Definition. — Down one of the inguinal canals, by the side of the 
round ligament, a loop of intestine, and sometimes a portion of the 
mesentery, an ovary, the bladder, or the entire uterus, may pass, as 
inguinal hernia occurs in the male. 

The fact that this disease is by no means frequent makes its recog- 
nition the more important, for Avere the practitioner not aware of the 
possibility of its occurrence the intestine might be wounded, under the 
supposition that the labial enlargement was due to abscess or distension 
of the vulvo-vaginal glands. 

Causes. — The displacement may be produced by violent muscular 
efforts or blows or falls, as in the male. 

Symptoms. — On the whole, intestinal hernia does not differ in the 
S3 T mptoms it produces in the female from those caused by the same con- 
dition in the male. Strangulation of the intestine with its characteristic 
signs may occur, although it is very rare. The hernia may usually be 
overcome by taxis. In one case with which we met reduction was 
extremely difficult, and could only be accomplished by prolonged effort. 
When the intestine becomes prolapsed, no strangulation existing, a sense 
of discomfort upon bending the body, or even upon walking, directs 
the patient's attention to the affected part and leads her to apply to the 
physician. By him the nature of the case will at once be suspected 
from the peculiar gaseous or airy sensation yielded to the touch. Cer- 
tainty of diagnosis will be arrived at by absence of all signs of inflam- 
mation or oedema, the detection of impulse upon coughing and resonance 
upon percussion, and the possibility of diminishing the volume of the 
tumor by taxis and position. There are no very great difficulties attend- 
ing the differentiation of the disease. The danger is that the possibility 
of hernia at this point may be forgotten, and deductions drawn without 
considering it. Although the probability of error be not great, the 
appalling nature of the accident in which it would result warrants the 
relation of the following case, which is illustrative of its possibility. A 
patient called upon us with the following history : She had had an abscess 
just below the external abdominal ring, which, after poulticing, had 
been evacuated by her physician about a month before the time of her 
visit to us. After this she had felt well until a week before, when after 
a muscular effort the pain had returned with all the original signs of 



HYDROCELE. 141 

abscess, and these had continued, although she had painted the part 
steadily with tincture of iodine, as she had been directed to do in case 
of. such an occurrence. Being in great haste at the moment, we exam- 
ined the enlargement while the patient was standing, and under a recent 
cicatrix, which was painted with iodine, we discovered what we supposed 
to be a reaccumulation of pus. As the patient came to us, in the absence 
of her physician, merely for the evacuation of this, we placed her in 
the recumbent posture, and, lancet in hand, proceeded to operate. But, 
to our surprise, we discovered that change of posture diminished the 
size of the enlargement. This excited our suspicions, and we found that 
a recent hernia had occurred under the old cicatrix. 

A few cases are on record of hernia of the uterus even in its early 
pregnant condition, 1 and instances of hernia of one or both ovaries are 
not very uncommon. 

Treatment. — The patient having been placed upon the back with 
the hips elevated by a large cushion, or, as is better, by elevation of 
the foot of the bed or table upon which she lies, the tumor should 
be grasped, compressed and pushed up the canal down which it has 
descended, until it returns to the abdomen. Then a truss, so arranged 
as to press upon the inguinal canal, should be adjusted and worn with a 
perineal strap, to keep the compress of the instrument sufficiently low 
down to effectually close the point of exit. Should strangulation have 
occurred and return of the prolapsed part by taxis prove impossible, 
the case will require the surgical operation for that condition, for a 
description of which the reader is referred to works on general surgery. 
If the prolapsed uterus and ovaries can be replaced by taxis, they should 
be retained by a truss similar to that described ; but if the pregnant 
organ cannot be replaced, abortion will have to be first induced, and 
irreplaceable ovaries may have to be removed if they give rise to suf- 
ficient discomfort. 

Hydrocele. 

Definition and Frequency. — This affection, which consists in a col- 
lection of fluid in the inguinal canal around the round ligament, is one 
of such rarity in the female that its very existence is commonly ignored, 
and mention of it is rarely made by systematic writers. 2 [I myself 
have met with no instance of this disease ; but, rare as it is, it merits a 
description, if only for the sake of those of our colleagues who may 
happen to meet with it and will look in vain for information regarding 
it. Hence I have retained this section unchanged. — P. F. M.]. 

Anatomy. — It has been already stated that the labia majora of the 
female are analogous to the scrotum of the male, and that the round 
ligaments, which are analogous to the spermatic cords, do not end in the 
mons veneris, as was formerly supposed, but passing downward enter the 
labia majora and distribute jjheir filaments within the dartoid sacs, which 
extend like glove-fingers downward toward the fourchette. The inter- 
esting and valuable article of M. Broca upon this subject will be found 

1 I saw one such case while assistant to Scanzoni in 1868. The patient was four 
months pregnant, and abortion was successfully induced by me, — P. V. M. 
- Scanzoni's work upon Discuses of Women contains an account of it. 



142 DISEASES OF THE VULVA. 

quoted at length in Cruveilhier's Anatomy. The peritoneal covering 
of these ligaments usually extends to the inguinal canals, but occasion- 
ally in young subjects it is prolonged through a portion of the canal 
constituting the canal of Nuck. 1 In adults this is ordinarily obliter- 
ated, and hence the rarity of hydrocele and hernia in the female. 
Sometimes it remains permanently open, when not only may the intes- 
tines descend, but even the ovary may pass down, making an attempt 
to enter the dartoid sacs and imitate the entrance of the testes into the 
scrotum. 

Pathology. — The affection which we are now considering is the result 
of excessive secretion on the part of this serous membrane, which, by 
the fluid collected within it, is distended laterally and downward. Should 
the abdominal opening of such a sac remain pervious, the fluid thus 
collecting could readily be forced upward, as in the same aifection in the 
male, but if that opening has become impervious, the fluid becomes sac- 
culated and such return is impossible. So rare is this affection that we 
offer no apology for the introduction of the following instance of it, 2 
reported by Dr. E. P. Bennett of Danbury, Connecticut : 

'• In an extensive practice of over forty years but one single case has 
come under my observation. This case occurred recently in a young mar- 
ried female residing in Putnam county, and was mistaken for a case of 
inguinal hernia by a surgeon of some eminence, who endeavored to reduce 
it, but, failing to do so, pronounced it adherent and irreducible, and advised 
to let it alone. That such a mistake should have been made is not at all 
surprising, as it was a hydrocele of the round ligament coming down 
through the inguinal canal, and occupying exactly the place of inguinal 
hernia, and closely resembling one. She subsequently came under my care, 
and upon inquiry I learned that about five years since a small tumor had 
made its appearance, which had slowly and steadily increased in size until 
it had attained its present size, which was about as large as a turkey's egg. 
It had not been painful, was not attended with abdominal disturbance, had 
never receded when recumbent, and gave to the touch a feeling of fluid con- 
tents instead of the doughy feel of hernia, and I therefore thought that, 
whatever it might be, it was not hernia ; and upon closer inspection I dia- 
gnosed hydrocele of the round ligament, although it was not diaphanous. 
So sure was I of a correct diagnosis that I at once proposed an operation, 
to which she readily consented, and with the aid of a professional brother, 
who coincided with me in my diagnosis, I proceeded to cautiously lay open 
the sac, when we found, to our great satisfaction, that we had not blundered 
in our opinion. The serous contents of the sac having been evacuated, I 
injected it with a saturated tincture of iodine, and she speedily recovered 
without the supervention of a single unpleasant symptom. This case is 
only important from its rarity, and the fact that most physicians are not 
aware that hydrocele can or ever does occur in the female ; and my object 
in writing this article is not to record any remarkable achievement in sur- 
gery, but to call the attention of physicians to the subject, and thereby 
prevent mistakes which might be attended with disastrous results." 

A pamphlet has been published upon the subject by Dr. Hart of 
New York. In it he details an operation for hernia performed in a case 

1 Cyclopedia of Anat. and Phys., Supplement, p. 706. 

2 N. Y. Med.* Record, Nov. 15, 1870. 



PRURITUS VULVJE. 143 

of hydrocele from a mistake in diagnosis. The fluid of the hydrocele 
being evacuated, the wound was closed by silver suture and the patient 
recovered. He declares that the disease is mentioned by Aetius, Pare, 
Scarpa, Meckel, and Poland. 

Differentiation. — The greatest circumspection should be observed 
before a diagnosis of this rare malady is arrived at. The sense of fluc- 
tuation, with entire absence of symptoms of inflammation, the absence 
of resonance on percussion and the ordinary signs of hernia, the exist- 
ence of translucency, and the gradual development of the tumor with- 
out pain or constitutional excitement, would all be reasons for suspect- 
ing it. But before ultimate measures are adopted for its cure a very 
fine exploring needle — such, for example, as that of the ordinary 
hypodermic syringe — should be passed in, in order that the contents 
of the sac may be carefully examined. 

Should the character of this fluid not assure us that hernia exists, 
the smallest needle of the aspirator should be introduced and all the 
fluid drawn off. Even where hernia exists such a procedure has been 
found to favor return of the sac and to do no harm by rendering it 
subsequently pervious. 

Treatment. — The diagnosis being made, the treatment should con- 
sist in evacuation by means of the aspirator, and, if cure do not follow 
this, in the injection of tincture of iodine in addition, which may be 
done by reversing the action of the same instrument. 



CHAPTER IX. 
PRURITUS VULVAE. 

Definition. — This affection consists iri irritability of the nerves sup- 
plying the vulva, which induces the most intense itching and desire to 
scratch and rub the parts. Although not itself a disease, it is always 
so important, and often so obscure a symptom, that it requires special 
notice and investigation. 

Pathology. — It has just been stated that it consists in disorder of 
the nerves supplying the vulva. It matters not whether this be a true 
neurosis or one secondary to some other pathological state, the great ele- 
ment of pruritus vulvae is nervous irritability or hyperesthesia. That 
it is often excited by irritating discharges (the saccharine urine of dia- 
betes and acrid utero-vaginal secretions) and eruptive disorders there 
can be no question. Whether it ever depends upon idiopathic nervous 
hyperaesthesia, as some suppose, is doubtful. We have never met 
with an instance in which it appeared to do so. 

Mode of Development and Course. — In the beginning the irritabil- 
ity and tendency to scratch are sometimes very slight, so as to annoy 
the patient very little and give her but trifling uneasiness. Sometimes 
they exist only after exertion in warm weather, upon exposure to arti- 
ficial heat, or just before and after menstruation. The disorder is 



144 DISEASES OF THE VULVA. 

aggravated by the counter-irritation which it demands for its relief. 
The rubbing and scratching that are practised cause an afflux of blood, 
render the skin tender and its nerves sensitive, and in time greatlv 
augment the evil by producing a papular eruption. The disease and the 
remedy which instinct suggests react upon each other, the first requir- 
ing the second, and the second aggravating the first, until a most rebel- 
lious and deplorable condition is developed. It would be difficult to 
exaggerate the misery in some of these cases. The patient is bereft 
of sleep by night and tormented constantly by day, so that society 
becomes distasteful to her and she gives way to despondency and 
depression. The itching is generally intermittent, in some cases 
occurring at night, in others only at certain periods of the day. In two 
cases that we have met the patients were free from all irritation except 
at night, when the disturbance and nervous anxiety became so intense 
as to prevent sleep, except when large doses of opium were given. 
Loss of sleep, the use of opium, and the nervous disturbance incident 
to the disease often prostrate and exhaust the patient to an astonish- 
ing extent. 

This disorder is to some degree paroxysmal, any influence which 
produces congestion of the genital organs aggravating it very much. 
Lying in a warm bed, sexual intercourse, eating and drinking, more 
especially highly-seasoned food and stimulating beverages, and the act 
of ovulation, all produce this result. Its duration has no limit, months 
and even years sometimes passing before relief is obtained. 

Although the term "pruritus vulvae" is that ordinarily applied to 
it. it must not be supposed that the irritation is always confined to the 
vulva. It often extends up the vagina, to the anus, and down the 
thighs. In pregnant women we have repeatedly known it to spread 
over the abdomen. It may be asked why such a state should be styled 
* ; pruritus vulvae"? These extensions are merely complications of the 
original malady which really deserves that name, and are due to con- 
tamination, by scratching, with an ichorous element which constitutes, 
as we believe, the prominent exciting cause of the trouble. 

Causes. — Every practitioner dreads to meet with an aggravated case 
of pruritus vulvae, for he knows how obstinate the malady commonly 
proves. The only reasonable hope of controlling it must rest in view- 
ing it strictly as a symptom and striving to discover and remove its 
cause. No fixed prescriptions, however much lauded for their efficacy, 
should be relied upon. The primary disorder should be sought for and 
cured, in the hope of removing that one of its results which is most 
pressing in its demands for relief. Should the case have progressed 
for some time, it will often be found impossible to decide as to its cause, 
for the scratching induced by it will frequently establish a cutaneous 
disorder, the connection of which with the pruritus, whether as cause or 
effect, will be doubtful. 

The predisposing causes of pruritus are the following : 
Uterine, vaginal, or urethral disease ; 
Pregnancy ; 

Depreciated general health ; 
Habits of indolence, luxurv, or vice ; 



PRURITUS VULVJS. 145 

Want of cleanliness ; 

Severe exercise in one of sedentary habits. 
It will be observed that most of these influences are those which 
predispose to the development of abnormal secretion by the mucous 
membrane lining the genital tract. Such excessive and deranged 
secretion we believe to be in the great majority of cases the immediate 
exciting cause of the nervous irritation. That there are other causes it 
will be seen that we admit, but to treat this condition successfully we 
are convinced that special reference must be had to this element. He 
who simply keeps in view the local trouble, in the majority of cases will 
be striving merely against the branches of an evil the root of which 
consists in the ichorous material which bathes and excoriates the ter- 
minal extremities of the nerves of the vulva and vagina. 

In all the instances of pruritus vulvae that we have been able to 
examine early enough to determine as to the etiology we have found 
one of the following conditions to exist as the apparent cause of the 
hypenesthetic condition of the nerves : 

1st. Contact of an irritating discharge — 

Acute and chronic endometritis and vaginitis ; 
Discharge of cancer ; 
Incontinence of urine ; 
Diabetes. 
2d. Local inflammation — 
Vulvitis ; 
Urethritis ; 
Vaginitis ; 
Follicular ulcers. 
3d. Local irritation — 

Eruptions on the vulva ; 
Animal parasites ; 
Onanism ; 

Vegetations on the vulva ; 
Vascular urethral caruncles ; 

Growth of short, bristly hair on mucous face of labia. 
Of all these, endometritis and vaginitis are the most frequent causes. 
The discharge from these diseases fortunately produces pruritus onlv as 
an exception to a rule. Under certain circumstances it appears to pos- 
sess peculiarly irritating and excoriating qualities, which, even when 
the flow is insignificant in amount, will excite the most intolerable 
itching, This feature is most commonly observed in the discharge 
attending pregnancy and in that of senile endometritis, which covers the 
vagina with bright red spots and gives it a glazed look like serous 
membrane. 

[In an exceedingly obstinate case occurring in a woman of seventy years, 
the leucorrhoeal discharge was so small in amount that the patient was not 
aware of its existence, nor did I appreciate its connection witli the disorder 
until I discovered accidentally that the only relief which could be obtained 
followed the application of a wad of cotton against the cervix uteri. In 
every case of pruritus the vagina should he carefully investigated for 
evidence of leucorrhoea, unless some other sufficient cause is apparent. In 
10 



146 DISEASES OF THE VULVA. 

the same manner the other discharges mentioned may cause nervous irrita- 
bility in the vulva.— T. G. T.] 

We have so often found diabetes accompanied by this symptom that 
we always examine the urine in obscure cases. It is by many attrib- 
uted to the constitutional agency of the disease. The marked relief 
afforded by the systematic use of the catheter has led us to think other- 
wise. Our impression is that the pruritus is probably not connected 
with the constitutional effects of the disease upon the nerves, but with 
the direct and local influence exerted by the disordered secretion, 
probably in consequence of the fermentation of the saccharine ingre- 
dients of the urine. 

Local inflammation, by the discharge which it excites and the itching 
which attends it, is very evidently calculated to give rise to pruritus, 
and yet cases thus established are not the most rebellious with which 
we meet. 

Any form of eruption upon or around the vulva may, and usually 
does, excite itching. Eczema, prurigo, lichen, and many others may 
do so here as they do elsewhere, and the natural warmth of the part, 
formed as it is of folds of tissue and covered by hair which is thickly 
interspersed with sebaceous and piliferous glands, makes them the more 
likely to prove active in causing it. 

Animal parasites of two varieties may give rise to it — the pediculus 
pubis and the acarus scabiei. The first excites through irritation a 
lichenoid eruption, while the second produces scabies or itch. 

One of these causes will generally be found to have given rise to 
pruritus vulvae, but it is only in originating the difficulty that it will 
prove active. Very soon secondary influences, as eruptions, excoria- 
tions, ulcerations, and increased discharges, the results of scratching, 
superadd themselves as auxiliary agents and keep up the disorder. 

Treatment. — It has been stated that the first effort of the prac- 
titioner should always be to discover the disease of which the pruritus 
is a symptom, and then to endeavor to remove it by appropriate means. 
Should leucorrhoea be the cause, the uterine or vaginal affection which 
gives rise to it should be treated. Should an eruptive disorder be 
found to be the source of the difficulty, the measures which would 
be advisable for this affection elsewhere developed — laxatives, baths, 
change of air, tonics, and arsenic — would be equally beneficial here. 

But this alone will not be sufficient. While eradication of the mis- 
chief is thus attempted, palliative means must be vigorously adopted 
for the sake of present relief. Should the case be regarded, upon 
careful investigation, as due to contact of an irritating fluid with the 
nerves of the vulva, perfect cleanliness should be secured by three, 
four, or, if necessary, a larger number of sitz-baths daily, and the 
vagina should at the time of taking each bath be syringed out with 
pure or medicated water. The irritated surface should be protected 
by unctuous substances or inert powders, such as bismuth, lycopo- 
dium, or starch, from the injurious contact, and in case the discharge 
comes from the uterus, a wad of cotton should be placed daily against 
the cervix uteri to prevent its escape to the vulva, or, as is better, 
after a thorough use of the vaginal douche the vagina should be 



PRURITUS VULVAE. 147 

tamponed daily with cotton saturated with glycerin, to which has been 
added borax or acetate of lead, two drachms to the ounce. Of this 
plan, which we should mention does not confine the patient to bed, we 
can speak in high terms. While it protects the vulva from ichorous 
discharges, it does not prevent ablution and applications to the point 
of maximum irritation. A very useful vaginal injection and wash for 
the vulva under these circumstances is the following : 



. Plumbi acetatis, 


3ij ; 


Acidi carbolici, 


By; 


Tr. opii, 


8; 


Aquae, 


Oiv.— M 



This may relieve itching for a time, until removal of the cause of 
the symptom is accomplished. 

In case the pruritus is the result of a local inflammation, this should 
be treated, as elsewhere recommended, by poultices of linseed, potato, 
or slippery elm, to which have been added a proper amount of lead 
and opium ; or fomentations of lead-and-opium wash or poppy-heads 
may be used in their stead. If vaginitis or vulvitis be present, great 
relief will often be obtained by painting the lining membrane of the 
diseased part with a strong solution of nitrate of silver, or by touch- 
ing the whole surface very lightly with the solid stick and then using 
the tampon of cotton and glycerin. 

Should an eruptive disorder be the exciting cause, it should, as 
already stated, be treated upon general principles. Meantime, tem- 
porary relief may be obtained by painting the surface of the vulva 
with a solution of nitrate of silver, or by the use of the ungt. crea- 
soti, ungt. chloroformi, or ungt. atropine of the U. S. Dispensatory. 
Dr. Simpson advises an infusion of tobacco, and Dr. J. C. Osborn 1 
of Alabama, in an interesting article upon the medicinal use of this 
drug, declares that he always resorts to a strong decoction of it as a 
wash for the vagina and vulva in this affection, and for the anus in 
"prurigo podicis." According to the latter gentleman, the local seda- 
tive effects of tobacco are very useful in the control of prurigo. Our 
own experience agrees with his. 

Although the fact will probably not prove one of practical value, it 
is certainly one of interest that cases have recently been reported in 
which smoking tobacco has appeared to relieve pruritus. 

[As an illustration I quote the following : " Mrs. W , 2 a woman of 

nervous temperament, became pregnant a few months after her marriage. 
In addition to the usual derangement of the alimentary canal, she soon expe- 
rienced a severe itching all over her body. The skin was of a perfectly 
normal appearance; the pruritus, however, caused her great excitement and 
soon produced nervous spasms. For several weeks every possible external 
and internal remedy was used in vain. A decoction of walnut-leaves gave 
her some relief when in the seventh month of pregnancy. Then a violent 
pyrosis and neuralgia of the dental nerves supervened. In order to alleviate 

1 .V. 0. Med. and Surg. Journal, Nov., 1866. 

2 Tribune Med., Jan. 31, 1869; Wiener med. Wochenschrift, No. 22, 1869, 



148 DISEASES OF THE VULVA. 

the latter, she was advised by her husband to try the effect of smoking, when 
the pain as well as the itching and pyrosis disappeared immediately. Mrs. 

W smoked one cigar every evening until she was prematurely delivered 

by a fright, after eight and a half months. 

" Fourteen months afterward Mrs. W again became pregnant, and was 

again affected in the fourth month of pregnancy with pruritus followed by 
pyrosis. She did not immediately resort to smoking, from the dislike of this 
habit, until the evil increased, when the smoking of one cigar again rendered 
her perfectly comfortable." — T. G. T.] 

No local application has acquired a more universal popularity in the 
treatment of pruritus vulvae than solutions of corrosive sublimate. The 
following formula is a good one of its kind : 

1^. Hydrarg. bichloridi, 3ss ; 

Tr. opii, 5j ; 

Aquae, gvij. — M. 
S. For external use only. 

Should eczema or lichen have produced inflammatory action in the 
skin and subcutaneous areolar tissue, poultices, etc. should be employed, 
as if local inflammation were the cause of the affection. 

While these palliative and curative means are being adopted, sleep 
should be secured by preparations of opium or one of its substitutes, 
codeine, chloral, hyoscyamus, or chlorodyne. At the same time the gen- 
eral state of the patient should be improved by vegetable and mineral 
tonics, good food, and fresh air. In some cases more benefit will arise 
from the use of iron, the mineral acids, and sea-bathing than from any 
other means. 

In certain cases dependent upon chronic vaginitis, or chronic endo- 
metritis which has resulted in vaginitis, the disorder will be found to be 
rather "pruritus vaginae" than "pruritus vulvae," and under these cir- 
cumstances the severity of the local and general disturbance may be 
very great. In such cases we have found great benefit from the fre- 
quent use of copious vaginal injections of warm infusion of bran. The 
patient, in the semi-recumbent posture, with the nates over a tub con- 
taining three or four quarts of this, with from six to eight drachms 
of laudanum and one to two drachms of acetate of lead dissolved in it, 
should inject the vagina freely for from ten to fifteen minutes, and this 
should be repeated four or five times a day. After a short time 
the soothing and alterative influence which it exerts will show itself 
so decidedly that less assiduous attention to the disorder will be 
demanded. 

In the same way infusion of tobacco and solutions containing borax, 
lead, alum, zinc, or carbolic acid will be found to be very valuable rem- 
edies. They should be used very freely and after previous cleansing of 
the vagina by pure water. One great difficulty in the treatment of the 
disease consists of the inefficient manner in which vaginal injections are 
practised by patients. This should be guarded against by explicit 
directions, and the use of the means suggested hereafter in connection 
with that subject. 



PRURITUS VULVAE. 149 

The following prescriptions have obtained a reputation for the treat- 
ment of pruritus, and we know by experience that they deserve it : 

1^. Chloroformi, 3J ; 

01. amygdalarum, 3j. — M. 

S. Apply to vulva and outlet of vagina. 

1^. Acidi hydrocyan. dil., £ij ; 
Plumbi diacetatis, Bj ; 

Olei cacao, §ij. — M. 

S. Apply after washing with cold water. 

1^. Lotionis nigri, Oj ; 

Soclse biborat., gj ; 

Morphise sulphat., gr. v. — M. 

S. Apply after bathing the part. 

1^. Acidi tannici, gr. c ; 

Belladonnae ext., gr. x ; 

Butyr. cacao, q. s. ; 

M. et ft. supposit. vag., xx. 
S. Let the patient place one in contact with the cervix uteri every 
night, after thoroughly syringing the vagina. 

Where diabetes exists as a cause the patient should bathe the parts 
after urination, and be instructed to keep the vulva thoroughly covered 
and protected by one of the ointments already mentioned. A reduction 
of the sugar in the urine by means of the proper dietetic treatment 
indicated in this disease is essential to permanent relief from the pruritus. 

Where the pediculus pubis is found to exist mild mercurial ointment 
should be applied ; and for the acarus scabiei sulphur ointment will be 
found sufficient as a parasiticide. 

When the itching is located in the skin of the mons veneris and 
surrounding parts, rubbing it freely with a moist stick of nitrate of 
silver is often of great service. 

Where short, bristly hairs are found growing from the inner or 
mucous surface of the labia majora great relief follows depilation. 
Each hair should be seized by forceps, the operator using a magnify ing- 
glass, and jerked from its place. 

It has been our experience that all cases of pruritus vulvae depend- 
ent upon local irritation are comparatively easy of cure by removing the 
cause, which is usually possible, except perhaps in very intractable 
endometritis, which is only too liable to recur. But when there is no 
local irritation present, and no acrid discharge from the vagina, the 
skin of the vulva being neither inflamed nor eroded, except by the 
finger-nails of the patient — that is, where the disease is of a purely 
neurotic character — we have found local treatment of but little avail, 
and have been obliged to resort to constitutional remedies, such as the 
bromides, arsenic, quinine, and iron, and to a change of climate and 
diet in order to secure any kind of a beneficial result. Morphine and 



150 DISEASES OF THE VULVA. 

other narcotics should be used with extreme caution in order to avoid 
an acquisition of the habit. 

[Hyperesthesia of the Vulva. 

Definition. — The disease which Ave proceed to describe under this 
name, although to all appearances one of trivial character, really con- 
stitutes, on account of its excessive obstinacy and the great influence 
which it obtains over the mind of the patient, a malady of a great deal 
of importance. It consists in an excessive sensibility of the nerves 
supplying the mucous membrane of some portion of the vulva ; some- 
times the area of tenderness is confined to the vestibule, at other times 
to one labium minus, at others to the meatus urinarius ; and again a 
number of these parts may be simultaneously affected. It is a condition 
of the vulva closely resembling that hyperaesthetic state of the remains 
of the hymen which constitutes one form of vaginismus. In two cases 
I have seen the whole surface of the vulva, except the labia majora, 
affected by an excessive sensibility which extended along the urethra. 

Frequency. — This disorder, although fortunately not very frequent, 
is by no means very rare. So commonly is it met with at least that it 
becomes a matter of surprise that it has not been more generally and 
fully described. 

Pathology. — It is not a true neuralgia, but an abnormal sensitive- 
ness — "a plus state of excitability" — in the diseased nerves. No in- 
flammatory action affects the tender surface, no pruritus attends the 
condition, and physical examination reveals nothing except occasional 
spots of erythematous redness scattered here and there. The nerve- 
state appears identical with that which sometimes develops in the scalp 
and on parts of the cutaneous surface. The slightest friction excites 
intolerable pain and nervousness ; even a cold and unexpected current 
of air produces discomfort ; and any degree of pressure is absolutely 
intolerable. For this reason sexual intercourse becomes a source of 
great discomfort, even when the ostium vaginae is large and free from 
disease. It is this difficulty which generally first causes the patient to 
apply to a physician for relief. 

Causes. — The predisposing causes appear to be the period of life 
near or at the menopause, the hysterical diathesis, or a morbid men- 
tal state characterized by tendency to depression of spirits. As ex- 
citing causes I have found chronic vulvitis and irritable urethral 
tumors to exist in some cases, but in others no cause whatever has 
been apparent. 

Symptoms. — I have said so much on this subject under the head 
of Definition that I have little more to add. The patient applies for 
relief because the act of sexual intercourse is painful, and because in the 
sensitive spot there is always a degree of discomfort which is increased 
by bathing the part or even by the friction incident to walking. Upon 
questioning her, it will be observed that her mind is disproportionately 
disturbed and depressed by this. In some cases it seems to absorb all 
the thoughts and to produce a state bordering upon monomania. 

Differentiation. — It should be distinguished from irritable urethral 



IRRITABLE URETHRAL CARUNCLE. 151 

tumor and vaginismus, which will be readily accomplished by inspection 
and touch. 

Treatment. — The treatment of this condition is most unsatisfactory. 
I have met with a number of cases of marked character, and in not 
one was complete relief given by treatment. Whether they subse- 
quently recovered I cannot say, but they certainly were not cured 
while under my observation. In one case, which I saw with Dr. 
Metcalfe, the sensitive area was the vestibule, and to this I applied 
nitric acid so as to destroy the mucous membrane completely, and 
followed this up by local sedatives, but to no purpose. In another, 
which I attended with Dr. Sims, he removed portions of the labia 
minora and of the vulvar mucous membrane, without success. In 
another case I dissected off all the sensitive tissue, which was quite 
extensive. This patient, the wife of a clergyman, left me well, and was 
greatly rejoiced; but in six months I received a letter from her 
declaring that she was worse than before the operation. The treatment 
which I would recommend from my experience is this : to send the 
patient away from home, where, in addition to enjoying change of air, 
scene, and surroundings, she would live absque marito ; to put her upon 
the use of general tonics, as arsenic, strychnine, quinine, and iron ; and 
after having cured any local exciting disease, like vulvitis or urethral 
vegetations or tumors, to make frequent ablutions with warm water, and 
apply sedative and calmative substances in the form of lotions or oint- 
ments. As examples of these, I would mention opium or its salts, 
carbolic acid, chloroform, belladonna, and iodoform. Sometimes ben- 
efit seems to result from strong solutions of alum, tannin, and similar 
agents. 

My observation of the results of caustics and the knife is not such 
as to inspire me with confidence in them.] 1 

Irritable Urethral Caruncle. 

Just at the edge of the meatus urinarius, and sometimes along its 
walls for some distance, little vascular tumors develop themselves, which 
render this canal very irritable, and in this way produce a great deal of 
discomfort. 

Pathology. — They consist of hypertrophied papillae, which as they 
enlarge are accompanied by excessive growth of areolar tissue. They 
are extremely vascular, capillary vessels of considerable size being 
found within them ramifying in transverse sections, very much like the 
vasa vorticosa of the choroid. They are richly supplied with nervous 
filaments. These two anatomical facts account for two corresponding 
clinical observations — that they bleed very freely and readily, and that 
they are almost as sensitive to the touch as a neuroma. 

Causes. — Of the etiology of this affection nothing is known. It 
develops in the young and old, the married and single. Probably 
irritation by some pathological form of urine has much to do with the 
growth of the caruncles. 

1 1 have never seen an instance of this disease, but Dr. Thomas assures me o{ its 
undoubted occurrence in his practice. Hence I reproduce this section unchanged. — 
P. F. M. 



152 DISEASES OF THE VULVA. 

Symptoms. — The patient complains of pain upon sexual intercourse, 
in passing urine, in walking, and upon the slightest contact of the 
clothing. She is disturbed by these means and by the increase of 
sensitiveness engendered by the warmth of the bed. As a consequence 
she becomes nervous, hysterical, and greatly depressed in spirits. Her 
whole thoughts often become fixed upon this one painfully absorbing 
topic, and a most wretched mental state is at times produced. Of 
course these grave results occur only in very aggravated cases, but 
even in minor ones they are present in slight degree. 

[Dr. T. F. Cock informed me of a case in which a patient became 
so much depressed from this cause that she committed suicide, and I 
have a similar statement of another case from a non-professional source. 
In the latter the time had been appointed for the removal of the growth 
when the patient destroyed her life. — T. G. T.] We should be sorry 
to leave the impression that mental alienation of grave character is 
likely to develop from these little growths ; it is not. A certain degree 
of it is very apt to be met with, and in rare cases, where the suffering 
is very great, it sometimes becomes excessive. 

Physical Signs. — The patient being placed upon the back with the 
thighs flexed and the knees separated, inspection shows at the meatus 
urinarius a florid, vascular growth varying in size from that of a cherry- 
stone to that of a pigeon's egg. Scanzoni declares that they may grow 
to the size of a goose's egg. Sometimes, instead of one, quite a num- 
ber may be found, of small size, extending around the meatus or up the 
canal. Where the canal itself is invaded the cases are always very 
difficult of cure, on account of the difficulty in reaching the morbid 
developments. 

Differentiation. — There are but two conditions with which we have 
ever known the disease confounded. One is prolapsus urethrae or ever- 
sion of the mucous membrane of the canal ; the other syphilitic growths 
of warty character. From the first a careful examination will readily 
distinguish it, and when the second exists similar developments will be 
found upon other parts of the vulva. Besides, neither of these condi- 
tions is nearly so annoying and painful as that which we are considering. 

Course and Duration. — It is impossible to say how long these 
growths will continue to exist when not interfered with. We have 
known them last for years without continuing to develop, but retaining 
a small size and being always excessively sensitive and annoying. On 
the other hand, we have seen many cases in which the growths were 
neither sensitive to touch nor gave the patients the slightest incon- 
venience. 

Prognosis.— In. case a single large caruncle exists, an almost positive 
promise of relief may be held out from its removal; but where a num- 
ber of small, fungous, warty growths surround the meatus and extend 
up the urethra, cure is extremely difficult, for no sooner are they removed 
than the morbid process of development rapidly produces more. Another 
discouraging feature of these cases is this : a nervous hyperesthesia is 
engendered by the growth which lasts long after its removal. In order 
to ensure a permanent cure the diseased condition of the urine, or of 
the bladder (chronic cystitis) upon which the abnormal urine depends, 



IRRITABLE URETHRAL CARUNCLE. 



153 



must be rectified. An irritable condition of the urethra and the neck 
of the bladder is liable to follow the removal of the caruncle for some 
time, and it is well to notify the patient of this probability. 

Treatment. — Before operating the patient should be thoroughly 
anaesthetized and placed upon the back, with the thighs flexed and the 
knees widely separated. The labia being then separated by an assistant 
on each side, the tumor should be seized near its base by forceps, pulled 
toward the operator, and its attachment cut by scissors. Very free 
hemorrhage may occur. To control this, the raw surface should be 
wiped dry and thoroughly touched with fuming nitric acid, a stick of 
nitrate of silver, or the actual cautery. 

This operation may be very nicely performed by galvano-cautery, 
if an instrument be attainable. By this means not only is hemorrhage 
prevented, but the base is also thoroughly cauterized, which is a great 
safeguard against return of the growth. 

Where the urethra has been invaded it should be thoroughly stretched 
by little retractors introduced within it and held by assistants, and the 
growths thus exposed be cut off by scissors or scraped from their attach- 
ments by a steel curette. After removal their bases should be very cau- 

Fig. 52. 




Paquelin's Thermocautery. 

The apparatus consists of a hollow handle, insulated with wood to protect the hands from 
the heat. It is furnished with three movable, hollow, platinum cauteries : into these, after 
they have been heated to blackness in the flame of a spirit lamp, a blast of benzine vapor is 
introduced by means of a Richardson's spray bellows, which at once raises them to, and main- 
tains them at, a state of vivid incandescence. The heat thus produced can be kept up for an 
indefinite time by slightly compressing the bellows occasionally. 



tiously touched with nitric acid, or, what is still better as preventive 
of return, the actual cautery. A few years ago the actual cautery was 
an instrument so unmanageable and difficult of employment that it was 
rarely used for slight operations. Now, thanks to the genius of 



154 



DISEASES OF THE VULVA. 



Paquelin, whose instrument is shown above, it is used as easily as the 
stick of nitrate of silver. 

To avoid as much as possible the distressing tenesmus of the neck 
of the bladder which is almost sure to follow this operation, we usually 
dilate the urethra with uterine dressing-forceps or the steel two-branched 
dilator to a sufficient width to permit the introduction of the little finger 
into the bladder ; and not until this has been done do we apply the 
caustic or cautery. 

Urethral Venous Angioma. 

This is a disease affecting the urethro-vaginal tubercle or anterior 
half of the urethro-vaginal septum. It sometimes attains a large size 
and projects between the labia. From irritable caruncle or vascular 
excrescence it can be differentiated by its want of sensitiveness. 

It appears, says Savage, 1 to be due to venous congestion, analogous 
to that giving rise to priapism. 

Its treatment is identical with that of urethral caruncle. 



Prolapsus Urethrse. 

This accident, which has likewise been described as procidentia and 
eversio urethrse, consists of prolapse of the urethral mucous membrane, 

with proliferation of the underlying 
connective tissue. It is not com- 
monly met with, but at times pro- 
duces considerable irritation of the 
urethra and bladder, and leads to an 
erroneous diagnosis of irritable carun- 
cle. We have met with it in adults 
of enfeebled constitution and ad- 
vanced age and in little girls before 
the age of puberty. Diagnosis is 
easy. A roseate projection encircles 
the meatus, which is sensitive and 
liable to bleed. The only diseases 
with which it could be confounded 
are irritable caruncle, urethral poly- 
pus, venous angioma, and epithelioma. 
From all these it can readily be dif- 
ferentiated by careful examination, 
which shows that it entirely surrounds 
the meatus, while they do so only in 
part. The extreme sensitiveness of 
irritable caruncle is not a differential 
sign which can be relied upon, for we 
have seen prolapse of the urethra de- 
velop this symptom very decidedly. 
It may for some time exist without 
symptoms, but usually soon creates difficult and painful micturition, 
pruritus vulvae, and leucorrhoeal discharge. 

, op. cit. 




Prolapse of Urethra (Munde). 

From a girl nine years of age. Upper sound is 

in the urethra, lower in the vagina. 



CYST AND ABSCESS OF THE VULVO-VAGINAL GLANDS. 155 

Treatment. — The simplest method of treatment is to seize the pro- 
lapsed circle with tooth-forceps, the patient being anaesthetized, draw 
it down with very little force, and cut it off with curved scissors. The 
resulting hemorrhage is controlled and the calibre of the meatus main- 
tained intact by stitching the edge of the mucous membrane of the 
urethra to that of the mucous covering of the vestibule all around 
the opening. If able, the patient may pass water or it may be drawn 
by a catheter. 

In one case we drew down the prolapsed tissue, passed a double 
silk ligature through its base, and tied the two halves. The cure was 
perfect. 

Should obstinate hemorrhage follow any of these operations upon 
the urethra or vulva, a firm vaginal tampon with a T bandage, used so 
as to press its lowest portion against the bleeding surface, will readily 
control it. The former presses the urethra upward and the labia out- 
ward, while at the same time it gives a firm, fixed point, against which 
direct pressure by a T bandage and compress may be made. It pos- 
sesses more real value than all the other means usually mentioned for 
the control of such hemorrhages combined ; such, for example, as Mon- 
sel's salt, the actual cautery, strong acids, etc. The vulva is so 
exquisitely sensitive that the patient is apt to rebel against these, and 
in addition they often fail in accomplishing the result. 

Cyst and Abscess of the Vulvovaginal Glands. 

Anatomy. — Just anterior to the hymen, or the carunculae myrti- 
formes, will be found on each side a little opening sufficiently large to 
admit a small probe or bristle. This opening leads through a canal 
three-fifths of an inch long, which is the excretory duct of a conglome- 
rate gland which has received the name of the vulvo-vaginal gland. 
These glands are found on each side of the ostium vaginae, between 
the vagina and the ascending branch of the ischium, from which they 
are distant three-tenths of an inch, and lie in contact with the trans- 
verse artery of the perineum. The fact that they are separated from 
the vagina by an aponeurotic prolongation, lie between the superficial 
and middle layers of the ischio-pubic fascia, and have the unyielding 
ischium on one side, accounts for the complete confinement of pus 
forming in them and its not being discharged by the rectum or vagina. 
They were described by Duverney, Bartholin, Morgagni, and their 
immediate successors, but in time, very singularly, they were forgotten. 
In 1841, M. Huguier of Paris redescribed them fully and threw much 
light upon their diseased conditions. 

Sometimes, their mouths becoming occluded by adhesive inflamma- 
tion, their secretion is retained, and they undergo great enlargement 
and distension. At other times suppurative inflammation is set up and 
abscess is the result. 

Causes. — The causes of inflammation of these glands are very 
much the same as those of vulvitis, of which,' indeed, this affection is 
often a concomitant disorder. 

Symptoms. — These are heat on the affected side oi' the vulva, pru- 



156 



DISEASES OF THE VULVA. 



ritus, and pain upon touch. The mouth of the duct is red, and the 
finger pressed over the site of the gland discovers a hard, painful, and 
perhaps fluctuating tumor about the size of a small hen's egg. Very 
often the first intimation of the existence of the disease is given by 
pain during the sexual act or upon manipulation. 

Differentiation. — An abscess of 
this gland is generally readily dis- 
tinguished from ac} T st by the presence 
of the ordinary signs of inflammation, 
or, when cystic distension exists with- 
out inflammation, the locality of the 
round mass rolling slightly under the 
finger without tenderness will make 
the diagnosis clear. From phleg- 
monous inflammation of the labium 
majus it will be known by its distinct, 
globular, and limited outline, the for- 
mer affection being diffuse. Furun- 
cles are entirely too superficial to 
create confusion in diagnosis. 

Course and Duration. — The dis- 
ease is one of no great moment, and 
its natural tendency is to recovery. 
Its usual duration is from two to three 
weeks, and the inflammatory process 
may terminate either by resolution or 
by suppuration. Should the latter 
occur, the pus may be discharged 
through the ducts of the gland or in 
the furrow between the labia minora 
and majora. In some cases, however, 
the gland becomes filled with a honey-like matter, and exists as a cyst 
for months and even for years. 

Treatment. — When inflammation affects the cyst-wall an emollient 
poultice or cooling and anodyne lotion should be kept applied to the 
vulva, and rest should be prescribed until suppuration has occurred. 
Then, as soon as fluctuation is distinct, the accumulated pus should 
be evacuated by a long incision, extending from top to bottom of the 
inner face of the labium, and the cavity irrigated with a weak subli- 
mate solution and packed with iodoform gauze. To allow the abscess 
to open and heal spontaneously usually means its return in a few months 
on the occurrence of the slightest irritation of the parts, and this return 
may take place again and again at irregular intervals until finally the 
abscess is opened and radically treated. 

When retention of the contents of the gland has created a cyst 
unattended by suppuration, or when frequent return of suppurative 
action renders a radical procedure necessary, it has been advised to 
extirpate the gland. This is a bloody operation, as the transversus 
perinei artery is apt to be severed. In all our experience we have never 




Abscess of the Vulvovaginal Gland. 



COCCYGODYNIA. 157 

found extirpation necessary, and have practised in its stead the proce- 
dure which we shall now describe: 

Catching up the raucous membrane over the sac, we cut out with 
scissors an ellipse. This exposes perfectly the wall of the sac, which 
is punctured by the tenaculum, so as to allow the escape of a small 
amount, say one-third, of its contents. The sac-wall is now lifted by 
the tenaculum, and an elliptical piece is cut out of that also. This 
prevents closure and secures drainage. The cavity is now filled 
with carbolized cotton or iodoform gauze, which in thirty-six or forty- 
eight hours is removed. In obstinate abscesses and in cysts we usually 
swab the cavity with tincture of iodine before packing it, and occa- 
sionally scrape it first with the sharp curette. 

Coccygodynia. 

Definition and Frequency. — This affection consists in a morbid 
state of the coccyx or the muscles attached to it, which renders their 
contraction, and the consequent movement of the bone, very painful. 
It is of frequent occurrence, numerous cases having been observed, 
since attention has been called to it, by practitioners who saw it pre- 
viously without regarding it as a special disorder. 

History. — Coccygodynia was first described in 1844 by the late Dr. 
Nott. Under the name of neuralgia of the coccyx he described a case 
which fully embodies the symptoms and treatment of the affection by 
surgical resource. 1 

Although Dr. Nott gave every detail with which we are now 
familiar as to the symptomatology and treatment of this affection, the 
subject was nearly forgotten until the year 1861, when it was again 
described, almost simultaneously, by Simpson of Scotland, who gave it 
its name, and Scanzoni of Germany. We have in this another instance, 
of which so many exist, of the complete oblivion into which a few 
years may cast a valuable contribution to science. Surely in such 
a case he who revives what is forgotten deserves as much credit as he 
who originally made the discovery. 

Anatomy. — The coccyx serves as a point of attachment for the 
greater and lesser sacro-sciatic ligaments, the ischio-coccygei muscles, 
the sphincter ani, levatores ani, and some of the fibres of the glutei 
muscles. These are thrown into activity by certain movements, as 
rising from the sitting into the standing posture, the act of defecation, 
etc. ; and in such acts the existence of the disorder which we are con- 
sidering is revealed. 

Pathology. — The peculiar pain which characterizes this disease has, 
according to our experience, a variety of causes : we have removed one 
coccyx in which a fracture with dislocation received in early life, which 
caused it to jut in at a right angle to the sacrum, was its source: another 
in which, as in Dr. Nott's case, just recorded, caries existed : while in 
still a third no abnormal condition could be discovered. In such cases 
as the last the pain which characterizes it is probably due to a hyper- 
sensitive state of the fibrous tissues surrounding the coccyx or of that 

1 N. 0. Med. Journ., May, 1844. 



158 DISEASES OF THE VULVA. 

making up the tendinous expansions of the muscles. This ma} 7 at times 
be, as Prof. Simpson has suggested, of rheumatic character ; but it ap- 
pears to us that it is very generally a neuralgic state, due to uterine or 
ovarian disease, of which coccygodynia is a frequent consequence. 

As a rule, so long as the bone is uninfluenced by contraction of the 
muscles attached to it, no pain is experienced, but as soon as contrac- 
tion produces motion it is excited. 

Causes. — It occurs most frequently in women who have borne chil- 
dren, but it is by no means confined to them. We have on two occa- 
sions met with it in young unmarried ladies, and Herschelman reports 
two cases in children from four to five years of age. 

Its chief causes are the following : 
Blows or falls upon the coccyx ; 
Injuries inflicted by parturition ; 
The influence of cold and exposure ; 
Uterine and ovarian disease ; 
Horseback exercise; 1 (?) 
Neurasthenia. 

In a case mentioned by Courty the patient had the peculiar habit 
of sleeping with the buttocks uncovered and the sacrum pressed against 
the wall. In 9 of Scanzoni's cases the condition followed parturition ; 
in 5, the use of the obstetric forceps ; and in 2, horseback exercise was 
the only cause ascertainable. 

A typical symptom of that common female disease of the present 
day, general nervous exhaustion or neurasthenia, is pain in the coccyx. 
This pain is complained of as much in the morning after a night's rest 
as at night, when one would expect to hear of it after a fatiguing day. 
It is usually associated with the other typical pains of neurasthenia in 
the cervical and dorsal regions of the spinal column. A careful exam- 
ination reveals no pathological change in the bone. 

Symjrtoms. — The patient upon sitting down, rising, making any 
effort, or passing feces experiences severe pain over the coccyx. In 
some cases this is so severe as to cause the greatest dread of sudden 
or violent movement. In others the patient is unable to sit, on account 
of the discomfort caused by pressure on the bone. The most trying 
process is that of rising from a low seat, and to accomplish this the 
sufferer will obtain all the aid that is practicable by assistance with 
the hands, which will be placed as auxiliary supports upon the edges 
of the chair or stool upon which she rests. 

Differentiation. — The only conditions with which this may be con- 
founded are painful hemorrhoids, fissure of the anus, and a spasmodic 
condition about the muscles of this part due to ascarides in the rectum. 
From these a careful and thorough physical examination will always 
readily distinguish it. 

Prognosis. — Coccygodynia often lasts for years, annoying and dis- 
tressing the patient, but never to any degree depreciating her health 
or constitutional state. If left to nature it may wear itself out, but it 
is probable that it would generally remain for a long time if not relieved 
by art. 

1 Scanzoni, op. cit. 



COCCYGODYNIA. 159 

Treatment. — Before any plan of treatment is adopted care must be 
taken to discover whether the disorder is secondary to uterine disease 
or anal fissure. If it be so, the primary disorders, and not their 
results, should receive attention. 

If the coccygeal disease be primary, blistering, the use of morphia by 
the hypodermic method, and the persistent use of the galvanic current 
will often effect a cure. While they are being tried the use of iodoform 
as a rectal suppository may be employed with advantage, together with 
all general means calculated to improve the tone of the nervous system. 

Should these means do no good and the patient's condition demand 
relief, recourse should be had to one of two radical methods of cure — 
section of the diseased muscles or excision of the bone to which they 
are attached. The first, placed at our disposal by the late Prof. Simpson, 
consists in severing the attachments of all the coccygeal muscles ; the 
second, in extirpating the coccyx itself, after the plan of Dr. Nott. 

The first operation may be performed subcutaneously by an ordinary 
tenotomy-knife. This is passed under the skin at the lowest point of 
the coccyx, turned flat, and carried up between the skin and cellular 
tissue until its point reaches the sacro-coccygeal junction. Then it 
is turned so that in withdrawing it an incision may be made which 
entirely frees the coccyx from muscular attachments. The knife is 
then introduced on the other side so as to repeat the section there. As 
is usually the case in subcutaneous operations, no hemorrhage occurs 
unless some large vessel be injured. We have resorted to this pro- 
cedure but once, when we found it exceedingly difficult of accomplish- 
ment, and it proved an entire failure in giving relief. 

In fat women subcutaneous section of the muscles attached to the 
coccyx is by no means so easy a matter as one would suppose who has 
not made the experiment. Under these circumstances the operation is 
simplified and rendered more certain by making an incision down upon 
the coccyx, lifting the exposed extremity of this bone with the finger, 
and then with a pair of scissors severing the muscles. This procedure 
is both easy of performance and certain as to result ; that is, supposing 
that it is resorted to in a case really demanding it. 

Should detachment of the muscles fail, as it will do if the bone be 
diseased, an incision should be made over the coccyx, the bone laid bare 
by severance of attachments, and the whole of it removed by a pair of 
bone-forceps or disarticulated by the knife. By one of these procedures 
cure can be confidently promised, and as neither is attended by danger 
our resources in this affection may be regarded with great satisfaction. 

Many slight cases of coccygodynia occur, however, which pass away 
with time and palliative treatment. The gynecologist should take care 
that operation is not resorted to too early. In fact, increased expe- 
rience with these cases has led us to restrict removal of the bone almost 
wholly to instances where it is diseased, fractured, or dislocated. To 
remove a coccyx for pain, which is but a symptom of general spinal 
hyperemia and constitutional nervous depression, is obviously illogical. 



160 THE FEMALE PERINEUM. 



CHAPTER X. 



THE FEMALE PERINEUM : ITS ANATOMY, PHYSIOLOGY, AND 
PATHOLOGY. 

Formerly there existed very generally throughout the profession a 
difference of opinion as to whether a laceration of the perineum should 
be immediately repaired or not, or, indeed, whether such an injury was 
worthy of repair at any time. This doubt was due partly to imperfect 
and careless observation by the attending obstetrician or by the gynecol- 
ogist under whose care the case came later on, and partly to a confused 
and faulty comprehension of the normal anatomy of the parts involved 
and of the manner in which their repair should be brought about. Hence 
many cases even of aggravated laceration of the perineum were allowed 
to go untreated for years, their unfortunate possessors suffering from 
prolapsus of the vagina and uterus, and even from fecal incontinence, 
all of which might have been cured very readily by a plastic operation. 
It is true, operations for this injury have been devised for nearly one 
hundred years, chiefly by the Germans, of whom Dieffenbach and Lan- 
genbeck the elder proposed ingenious methods, which, however, were 
never generally adopted. Baker Brown and Savage again revived and 
perfected the operation, being followed by Sims, Emmet, and others, 
including ourselves, in this country. At the present day, chiefly as a 
result of the researches of the past twenty years, the subject of lacera- 
tion of the perineum and its operative treatment has been thoroughly 
studied by gynecologists throughout the civilized world, and in conse- 
quence of a more thorough understanding of the anatomy of the part 
and the evil results following the failure to close rents of any magni- 
tude, the necessity for, and the technique of, the operation have gradu- 
ally become more and more understood, until now there seems very little 
left to be learned on the subject. By the older authors not much is said 
of the texture of the perineum, except to pronounce it the floor of the 
pelvis, the space extending from the posterior commissure of the vulva 
to the anus, and composed of skin, cellular tissue, tendinous union of 
muscles, fat, and bounded above by the posterior Avail of the vagina and 
below by the anterior wall of the rectum. Nothing definite is said as 
to its function, and still less as to the results of its destruction and the 
method of its repair. From these old descriptions we hardly know in 
what light to look upon the female perineum ; from them it would appear 
to be simply a septum between the vagina and the rectum. We are 
indebted, we believe, to Dr. Savage of London for the demonstration 
of the fact that the perineum — or rather the perineal body, as we prefer 
to call this important part — is in the female a triangular wedge composed 
of muscles, fascia, and areolar tissue which fills the space intervening 
between the backward curve of the rectum and the forward curve of 
the vagina. It was Savage who first called this triangle the perineal 
body, and for the sake of convenience and the correct understanding 
of its shape and functions we have retained this term. 



ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 



161 



In order to show the student how incorrectly former textbooks have 
portrayed the relations of the pelvic organs of the female we have 
preserved the following figure (Fig. 56). The bladder, the vagina, and 
the rectum are there all shown in their expanded condition — a state of 
things which certainly never exists when these organs are empty. In 
nature, unless the bladder or rectum be full, they are usually in a more 
or less collapsed condition, and the walls of the vagina, instead of gaping 
as in the cut, are in apposition, except when distended by some foreign 
body. The anterior vaginal wall rests upon the posterior, and is sus- 
tained by it. The gentle passage of a small cylindrical or Sims specu- 
lum will make this fact quite evident. 
A vertical transverse section of the va- Fro - 55 - 

gina made on a frozen subject by Henle 
is represented in Fig. 55. 

Our idea of the true relations of the 
vagina, bladder, uterus, rectum, and peri- 
neum to each other is represented in Fig. 
57, which at first sight would seem to 



resemble the diagram 



in Fig. 56, but 




there are a number of important differ- 
ences : the uterus is lower in the pelvis, 
more inclined forward, and the vagina, 
instead of consisting of a canal with a sin- 
gle curve from behind forward, presents 
a double curve — first, a decided curve, 
from behind forward, and second, a very 
slight one, from above downward and 
backward. Our delineation of the pe- 
rineal body may seem exaggerated, but 
practically it is true, as can be easily 
verified by enclosing the part between 
the index in the rectum and the thumb 
in the vagina in any well-formed and 
well-nourished nulliparous woman. This 

triangle is bounded in front by the DOS- Vertical Transverse Section of tbe Soft 

. & m J I Parts at the Pelvic Outlet : La., I rethra; 

tenor vaginal wall, behind by the ante- Va., Vagina; R., Rectum; L., Levator 

rior rectal wall, and below by the skin 

extending from the posterior commissure to the anterior margin of 
the anus. Just above the upper angle of the triangle the vagina shows 
a depression into which the cervix projects, so that the finger in the rec- 
tum reaches the cervix much more easily than if passed into the vagina. 
It was intended in our cut to show the rectum and bladder empty with 
their walls in apposition. But this was found to be impracticable if the 
normal proportions of these movable organs were to be preserved. Of 
course this is but a schematic diagram ; indeed, it would be almost 
impossible to give a representation of the absolutely normal relations 
of these organs, since they are generally in a condition oi' mobility, 
owing to the difference in the fulness of the rectum and bladder and 
the normal mobility of the uterus during every voluntary motion 
and the functions of inspiration and expiration. We have merely 
n 



162 



THE FEMALE PERINEUM: 
Fig: 56. 




Diagram ordinarily used for Representing the Perineum. 
Fig. 57. 



I 



v 



\ 



*Vr* 



Normal Topography of Female Pelvic Organs (diagrammatic). 1 

depicted the organs as they would be likely to appear in a state of 
comparative rest. 

1 Even in this otherwise correct plate the rectum should be collapsed and its walls 
in contact. 



ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 163 

If the perineal body just described be regarded merely from a 
mechanical point of view as an inactive mass of tissue, its influence 
in the co-ordination of pelvic support may well be doubted. Let it be 
remembered that it rests inferiorly upon a set of muscles whose union 
occurs at the space between the anus and vulva. The contraction of 
these throws the perineal body forward and upward, presses it against 
the anterior wall of the vagina, and thus makes of it an active agent 
in giving support. In some cases this action is so strong as to become 
abnormal and to cause dyspareunia, or to render coition entirely imprac- 
ticable. So marked is this at times that the perineal body has to be 
cut through by the knife to overcome the difficulty. 

We are now prepared to appreciate the functions of the female peri- 
neum or perineal body ; for we feel that the whole triangle must be 
described as the female perineum if we ever intend to inculcate true, 
rational, and reliable precepts as to management of this part during 
labor and in reference to uterine displacements. Its functions are the 
following : 1st, it sustains the anterior wall of the rectum, and prevents 
a prolapse of this, which would inevitably drag downward the upper 
vaginal concavity, and with it the cervix uteri, and destroy the equilib- 
rium of the uterus ; 2d, it sustains the posterior vaginal wall, and pre- 
vents a prolapse of this, which would allow of rectocele ; 3d, upon the 
posterior vaginal wall rests the anterior, upon this the bladder, and 
against the bladder the uterus, all of which depend in great degree 
for support upon the perineal body ; 4th, it preserves a proper line of 
projection of the contents of bladder and rectum, and thus prevents 
the occurrence of tenesmus, a frequent cause of pelvic displacements. 

Before proceeding to state the consequences and results, immediate 
and remote, of laceration of the female perineum, we wish our position 
in regard to this portion of the female pelvic organs to be distinctly 
understood. We do not regard the female perineum as a separate part 
of the pelvic organs, but merely as a combination of muscles, areolar 
tissue, fat, nerves, and vessels, the muscular portion of which combina- 
tion unites in the central raphe, as the line extending from the posterior 
commissure to the sphincter ani is generally called. The chief force 
of the perineum lies in its muscles and their median attachments. The 
most important of these muscles are the two deep transversus perinei or 
levatores ani, which meet in the upper portion of the median line of the 
perineum, are attached on either side to the ramus pubis, and extend 
about two-thirds up the posterior wall of the vagina, encircling the pos- 
terior half of that canal. The cutaneous and subcutaneous portion of 
the perineum may be entirely destroyed down to the sphincter ani, with- 
out in any way disturbing the position or relations of the vagina or 
uterus, always provided that the junction of the levatores ani is not 
severed. If these are injured, or even if their union is merely relaxed, 
the posterior wall of the vagina undergoes subinvolution, remains 
redundant, and as a rule gradually prolapses. 

In the last edition of this work we endeavored to explain the sup- 
port given to the rectum, bladder, and uterus by a diagrammatic 
triangular wedge shoved in between the rectum and bladder, and which 
we have designated as the "perineal body" by comparing it to the 



164 



THE FEMALE PERINEUM: 



inverted keystone of an arch ; and, acting on this theory, we constructed 
several diagrams represented in that edition in support of our views, 



Fig. 58. 




Schematic Diagram of Perineal Body. 

We have since come to the conclusion that this position is not based 
upon sound anatomical principles and not entirely tenable. While we 

Fig. 59. 




The same, Perineal Body removed. 

have, therefore, retained the diagrams which show our view of the action 
of the "perineal body" in its relations to the other pelvic organs and 
the effects following its removal — namely, destruction of the attachments 



ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 165 

and loss of support of the bladder and rectum — we do not wish to he 
understood as still considering this triangular wedge of muscles, fascia, 
etc. between the rectum and vagina in the same light as we did when we 
wrote our last edition. We know that the diagrams are entirely sche- 
matic ; we know that the perineal body as there represented does not 
actually exist ; we know further that as it is there illustrated it can 
impossibly be entirely restored by any plastic operation ; and still we 
feel that the student, to whom so many conflicting statements and ideas 
are now presented by authorities to whom he is accustomed to look up 



Fig. 60. 



Fig. 61. 



\\.Jt ft 



; 




Front View. 1 Section View. 

The Perineal Body destroyed, the Rectal Wall descends. 

with veneration, will understand far better what the loss of the support 
of the perineum to the superincumbent pelvic organs of the female 
entails, and how culpable is his failure to restore this part to its normal 
condition, so far as lies within his power, if he sees, even in an exag- 
gerated degree, the important functions which this organ fulfils. In 
many of the later books on the diseases of women laceration of the 
perineum is merely spoken of as the separation of the tissues situated 
between the vagina and rectum. This injury is looked upon as a direct 
traumatism produced usually by parturition, the diagnosis, results, and 
treatment of which are exceedingly simple, and very tew pages are 
devoted to the discussion of the anatomy and physiology of the peri- 
1 The perineum in this cut should be shown more deeply lacerated. 



166 



THE FEMALE PERINEUM: 



Fig. 62. 




The Perineal Body destroyed, both Rectal and Vesical 
Walls descend. (Front view.) 



neum. By the German au- 
thors chiefly the accident is 
considered mostly from its 
surgical aspect, and the ef- 
forts of the operator are di- 
rected mainly toward restor- 
ing the part to its normal 
condition. 

A number of recent au- 
thors have taken the ground 
that the perineum is of no 
particular consequence any 
way, and that its presence 
or absence does not mate- 
rially influence the well- 
being of the woman. Hence 
they deride any attempt to 
attach special value to it 
and its functions, and en- 
deavor to substitute for it 
the two muscles which we 
have already mentioned — 
the levatores ani. We think 
these authors go entirely 
too far, and are simply 
touching the other extreme 
from the one occupied by 



those writers who believe 
the loss of the perineum to 
be responsible for every dis- 
placement of the uterus and 
vagina. We shall complete 
our remarks on the neces- 
sity for the operative res- 
toration of the perineum in 
the chapter devoted to that 
subj ect. 

The perineal body may 
lose its tonicity and efficiency 
from the following causes : 

1st. From constitutional 
feebleness ; 

2d. From feebleness the 
result of prolonged 
over-distension ; 

3d. From subinvolution ; 

4th. From senile atrophy ; 

5th. From laceration. 

In a very few cases, in 



Fig. 63. 




The Perineal Body destroyed, both Rectal and Vesical 
Walls descend. (Section view.) 



ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 167 

girls of weak, delicate fibre, the perineal body will, without other assign- 
able cause, be found to be totally worthless and entirely incapable of 
performing its functions. Such cases are not commonly met with, but 
they do unquestionably exist, and every practitioner of large experi- 
ence must have met with them. In such cases the virgin vagina pre- 
sents to the finger the characteristics of that which has given birth to 
children, and not only vaginal walls but perineum are extraordinarily 
relaxed. 

Either in the virgin, the nulliparous married woman, or the mul- 
tipara the uterus, from increase of its own weight or from suddenly 
applied pressure from above, may become suddenly or gradually com- 
pletely prolapsed. When such prolapse occurs and the uterus for a 
long time remains between the labia, the perineal body, by over-disten- 
sion, loses its power, and after restoration of the uterus to its place 
remains permanently enfeebled. This condition is likewise produced by 
inversion, the presence of a large fibrous polypus, or the wearing of 
large globular pessaries. 

As utero-gestation advances, not only does the uterus grow with the 
growth of the foetus : the vagina, uterine ligaments, perineum, and mam- 
mae likewise undergo a physiological hypertrophy, which continues 
till delivery. After this has taken place, that retrograde metamor- 
phosis styled involution may fail in any or all of these parts, which 
then remain large, lax, and wanting in contractile power. This failure 
may affect the perineum, in consequence of a laceration more or less 
profound and the absorption of septic material subsequently. Or it 
may occur, as subinvolution of other parts often does, without assign- 
able cause. We are not aware that this condition attracted any notice, 
as connected with the perineum, until attention was called to it in 
this work some years ago. As to its existence there can be no doubt, 
and it certainly produces evil results which are scarcely less striking 
than those resulting from laceration. The difficulty of accounting for 
complete loss of power, as evidenced by extreme relaxation of the peri- 
neum, will be recognized in the literature of this subject by an attempt 
to explain the condition by supposing that in such cases the perineal 
body has been sundered from above, without any laceration having been 
inflicted either upon its mucous or cutaneous surface. 

Subinvolution often affects vagina and perineum simultaneously, and 
although the latter appears to be normal in size and uninjured by the 
parturient process, it is found loose, atonic, and feeble. The anterior 
vaginal wall and bladder sag downward for want of support, and the 
posterior vaginal wall and rectum protrude over the ineffectual perineal 
barrier. Instances of this pathological condition are very common, and 
uterine displacement as a result of it will be frequently seen. 

Cases of complete uterine prolapse in very old women, in whom both 
uterus and vagina have long undergone senile atrophy, are not by any 
means rare. Here the uterus does not descend primarily, but an 
absorption of the adipose tissue, which is stored away around the 
vagina and serves as a support for it, occurs as the decadence of 
advancing age shows itself, and a perineum hitherto strong becomes 
inefficient and inactive. 



168 THE FEMALE PERINEUM: 

Rupture of the perineum may simply be described as a splitting of 
the perineal body. Laceration in the first degree splits the triangle, 
one side of which is covered by the vagina, only for a short distance ; 
one in the second degree splits it to its centre ; while those in the third 
and fourth divide the triangle entirely through, and at once remove the 
44 keystone " from its place in the arch. 

Destruction of the power and function of the perineal body, more 
frequently than anything else, includes anterior and posterior displace- 
ments of the uterus and prolapsus in its three degrees. Removal of the 
perineum does not take away support from the uterus, but it alters the 
shape and removes the supports of the vagina, and causes it to drag 
upon and displace the uterus as a direct tractor. 

A curious phenomenon, which occurs in about one out of a hundred 
cases of destruction of the power of the perineal body, while in itself 
not important, serves to show how markedly the relations of the pelvic 
organs are in this way impaired. We allude to entrance of air into the 
vagina. While the pelvic organs are in normal condition the close 
apposition of the vaginal walls, already alluded to, entirely excludes the 
spontaneous entrance of air, and at once expels it if forced in. Let the 
perineal body be entirely destroyed, however, and certain positions 
assumed by the woman draw air into the canal, which subsequently 
escapes with a disagreeably explosive sound. This occurrence has been 
described l under the names of garrulitas vulvae or flatus vaginalis, and 
deserves some attention, in view of the fact that it alarms patients, Avho 
are at a loss to account for it, and mortifies them by its happening at 
untoward times. 

So intimately are gynecology and obstetrics connected in reference 
to this subject that a few words upon its relations to the latter will not 
be inappropriate. It is no exaggeration to say that a very large pro- 
portion of female diseases take their origin in the mismanagement of the 
lying-in chamber. If this be so — and no gynecologist will deny it — to 
the obstetrician the importance of the perineum in this connection can- 
not be exaggerated. Its rupture furnishes one of the most fruitful 
sources for the absorption of septic elements, and we do not hesitate to 
say that thousands of women suffer throughout their lives from uterine 
displacements, engorgements, and vesical and rectal prolapse in conse- 
quence of injuries inflicted upon it during the parturient act. To an 
imperfect comprehension of the anatonry and functions of the perineum 
we attribute, in great degree, the impression entertained by many 
practitioners that, in spite of all that is said, its rupture, so long as it 
does not involve the anal sphincter, is a matter of little moment. This 
dangerous dogma — which, in our minds, renders him who entertains it 
an unfit person to be entrusted with the grave responsibilities of the 
lying-in chamber — is always based upon the fact that such a practi- 
tioner has seen many perinea ruptured during labor, even without 
interference on his part, and has, to use the common phrase, "heard 
nothing of them afterward." But such a loose method of drawing 
deductions is hazardous as well as unphilosophical. How do they who 
draw them know how many cases of uterine displacement or vesical and 

1 See an essay by Lohlein, Zeitschrifl fur Geburishiilfe unci Gyuukologie, vol. v. No. 1. 



ITS ANATOMY, PHYSIOLOGY, AND PATHOLOGY. 169 

rectal prolapse, treated by themselves or others, have been the remote 
consequences of perineal lacerations regarded at the time of their occur- 
rence as of no importance? To account for remote troubles occurring 
years afterward is equally simple in his philosophy, for has not the 
patient lifted heavy weights, or fallen, or does not the displaced and 
congested uterus present sufficient signs of " chronic metritis" to offer 
this as a scapegoat ? 

Let us suppose that the perineum has been torn during labor down 
to the sphincter ani muscle. In this accident the vagina is always 
torn, though the grave consequences attending that accident when 
occurring in the upper half of the canal are here prevented by the 
intervention of the triangle of dense elastic tissue which exists between 
the vagina and the rectum. An immediate consequence is the expo- 
sure of an extensive raw surface indisposed to heal by first intention, 
richly supplied with blood- and lymph-vessels, and quite near to chains 
of lymphatic glands, intrapelvic and inguinal. Over this surface the 
flow of an ichorous, fetid, and semi-putrid animal fluid must, in spite 
of the greatest precautions, steadily pass for from two to three weeks — 
a fluid consisting of decaying and flaking decidua, disorganized blood, 
and quantities of muco-pus. The wonder is, not that septicaemia 
occurs so often under these circumstances, but that so many cases 
escape it where everything seems so perfectly arranged to favor it. 
Let one imagine a wound an inch deep and an inch and a half long 
made in the thigh near the groin or on the arm near the axilla, and 
bathed every hour of the day with the lochial discharges of a parturient 
woman ! Would he regard the occurrence of lymphangitis, phlebitis, 
and erysipelas as being unlikely consequences ? And yet this is what 
occurs to every lacerated perineum, the wound thus treated being in no 
manner protected against the evils incident to such exposure. 

If cases of decided laceration of the perineum were closely followed 
up from the lying-in room to the end of life, and all the evils which 
immediately and remotely arise from this accident intelligently noted, 
the list would be a long one — all not, of course, showing themselves in 
every case, but some occurring to one woman and some to another. It 
may be thus presented : 

Septicaemia ; 

Anterior and posterior uterine displacement ; 

Prolapsus ; 

Cystocele ; 

Rectocele ; 

Uterine engorgement and hyperplasia ; 

Subinvolution of uterus and vagina ; 

Destruction of power of uterine ligaments ; 

Development of a tendency to abortion ; 

Impairment of sexual gratification to the male ; 

Neuralgia affecting the site of rupture. 
Presented thus, this array may appear unnecessarily formidable. 
but there is not one pathological condition mentioned the occurrence of 
which practical men will feel inclined to question as a consequence of 
puerperal laceration of the perineal body. 



170 PROLAPSE OF PELVIC VISCERA. 

A decided laceration having occurred, if the obstetrician be a man 
who has familiarized himself with the anatomy and physiology of the 
perineum, it is difficult to understand how he can doubt the propriety 
of early closure of the wound, both as immediately preventive of sep- 
ticaemia — for for forty-eight hours, during which the healing process 
seals together the freshly-cut surfaces, the uterine discharges are innoc- 
uous — and as remotely preventive of all the evils which have just 
been enumerated. Should the operation prove a success, the gain 
to the patient will be great ; if it prove a failure, no evil will have 
been done. 

That there are sources of failure for immediate operation inherent 
to the condition itself cannot be denied ; but equally fruitful sources 
for it are to be found in ignorance of the anatomy of the part to be 
repaired, the performance of the operation hurriedly and without sys- 
tem, and the fact that the obstetrician has cultivated no capacity for 
surgery. 

This question may here be very pertinently asked, If in the non- 
puerperal state the perineum should be severed completely down to the 
sphincter ani muscle, would prolapse of vaginal, rectal, and vesical walls 
necessarily occur ? X o, not necessarily, though in time probably. On 
three occasions we have done this for the delivery from the vagina of 
very large tumors, and to test the question we have delayed closure of 
the perineum. In no case did prolapse occur. And why did it not do 
so when it so commonly ensues upon rupture of the perineum in labor ? 
Because laceration of the perineum during labor or abortion is very 
commonly the cause of subinvolution of vagina and perineal body. 
The former remains a large, lax, unconvicting bag ; the latter, a vield- 
ing, unresisting mass of adipose tissue and skin. 

Even after labor prolapse of these parts does not always ensue upon 
rupture, even though the sphincter ani and posterior vaginal wall for 
some distance up the rectum be involved. In spite of the accident, 
involution goes on, the strength of the vaginal walls is recovered, and 
they are sustained, although their shape and direction are altered and 
they lack the support of the perineal body. But such an occurrence 
as this is the exception, and not the rule, and in spite of many such the 
rule stands unquestionable. 



CHAPTER XI. 

PROLAPSE OF VAGINA, BLADDER, RECTUM, AND INTESTINES. 

Prolapse of the Vagina. 

The remarks made in the preceding chapter being distinctly borne 
in mind, it will be easy for the student to get a comprehensive idea of 
prolapse of the pelvic viscera as a consequence of disability on the 
part of the perineum, and the subject may be dealt with much more 
cursorily than it could have been without them. 



PROLAPSE OF THE VAGINA. 171 

It might upon very valid grounds be maintained that prolapse of 
the vagina or rectum and bladder are so intimately connected with pro- 
lapsus uteri that this chapter should have been united with that upon 
the latter condition. We have especially avoided this course, for the 
reason that we wish to direct the reader's attention particularly to pro- 
lapse of the vagina as a primary condition — one often long existing 
without uterine descent, and very frequently preceding that state as a 
causative influence. For any repetition which may occur in the two 
chapters we offer no apology, in view of the great importance of both 
subjects. 

Definition and Synonyms. — The mechanism by which the pelvic- 
organs of the female are kept in their proper positions and relations to 
each other offers, in its simplicity and perfection, an excellent example 
of that adaptation of means to an end which is so often repeated in the 
animal economy. The uterus is so sustained that when necessity 
requires it, not only in pregnancy, but under a number of other circum- 
stances, it may rise or fall or tilt backward or forward, while the rectum, 
bladder, and lowest layer of small intestines are kept in place and 
allowed to distend and empty themselves without material change of 
relation. 

When the tone of the walls of the vagina is impaired, and they 
pouch into its own canal so as to fall downward toward the vulva, the 
condition is called prolapsus. 

It is an important question whether there can be prolapse of the 
vagina without rectocele, cystocele, or uterine prolapse. The anterior 
or upper wall of the vagina is closely bound to the base of the bladder 
and the front of the cervix uteri, and by means of the utero-sacral 
ligaments it is indirectly attached to the sacrum. This wall aids in 
support of the uterus, bladder, and small intestines. The posterior wall 
is not so firmly bound to the rectum, though the adhesion at the 
extremity of the utero-rectal pouch of peritoneum is quite strong. At 
the perineal septum, a point a short distance above the vulva and just 
at the upper edge of the perineal body, the muscular walls of the vagina 
pass off to attach themselves to the ischio-pubic rami. At that point 
the canal is constricted by the pubo-coccygeus, the true sphincter vaginae 
muscle. The mucous membrane of the canal passes down to the four- 
chette. These anatomical arrangements account for the fact that pro- 
lapse of the vagina without simultaneous displacement of one or more 
of its surrounding viscera is exceedingly rare, and that when it does 
occur as a distinct disease it is very ^enerallv found to affect only the 
posterior Avail. We have met with no case in which the anterior wall 
has decidedly prolapsed without coincident descent of the bladder, bur 
we have seen a few instances of prolapse of the posterior wall with- 
out alteration of the position of the rectum. Subinvolution, or redund- 
ancy of the posterior vaginal wall is very liable to simulate true rectocele. 

Pathology. — Any influence which impairs the natural tonicity and 
strength of the vaginal canal, rendering it abnormally voluminous and 
lax, which alters its natural shape and the incurvation of its walls, 
or which destroys its lower buttress or support, will tend to induce this 
affection. As pregnancy and parturition combine most, and often all. 



172 PROLAPSE OF PELVIC VISCERA. 

of these, they very generally furnish both predisposing and exciting 
causes. The development of the vagina, and increased weight of the 
uterus dependent upon the former, and the distension of the canal 
and enfeebling of the sphincter muscle incident to the latter, all unite 
in favoring prolapsus. As the fibre-cells which constitute the nascent 
state of the uterine muscular fibres develop, so as to make of the 
insignificant non-pregnant uterus the powerful organ which expels the 
child at full term, so do those of the vagina, the Fallopian tubes, 
and the uterine ligaments. By the process of involution, which dimin- 
ishes the size and weight of the uterus, these parts likewise return to 
their original dimensions. Those influences which arrest this im- 
portant process in the uterus, resulting in subinvolution, likewise 
affect it in the other parts mentioned and render them atonic and 
feeble. 

Prolapsus vaginae is very rare, except in those who have borne 
children, although it may occur. Sir Astley Cooper met with it in a 
girl aged seventeen who was admitted into Guy's Hospital for supposed 
prolapsus uteri, and Prof. Meigs 1 mentions that Dr. Mutter of Phila- 
delphia saw it occur in a child six months old in consequence of con- 
vulsions ; and Ave have seen several instances in young virginal sub- 
jects of forcible prolapse of the whole uterus and vagina, produced by 
a sudden powerful pressure from above, such as lifting a heavy weight 
or violent straining at stool. 

Causes. — From what has just been said the following causes will 
naturally suggest themselves as those most likely to produce this dis- 
placement : 

Violent efforts of the abdominal muscles ; 

Repeated parturition ; 

Senile atrophy of vaginal walls ; 

Rupture of perineum ; 

Previous distension by tumors ; 

Subinvolution of the vagina and perineum. 
Of all these causes, the last is the most frequent, more especially 
when it accompanies, as it often does, partial rupture of the perineum. 
Xext in frequency stand senile atrophy and absorption of surrounding 
adipose tissue. 

It is evident that all act either by debilitating the power of the 
vaginal walls by mere mechanical distension, by specifically robbing 
them of their tonicity, or by removing the buttress against which the 
canal rests at the vulva. 

Varieties. — The displacement may be of two forms, acute and 
chronic. The power of the canal may be overcome by a violent effort, 
a fit of coughing, uterine or abdominal contractions, or similar acts 
which with great suddenness force the contents of the abdomen down 
upon the pelvic viscera. This occurrence, which is very rare, is gen- 
erally accompanied by sudden descent of the uterus or occurs soon after 
parturition. The ordinary form of the affection is that in which by 
the slow and steady action of one or more of the causes enumerated 
the resistance of the vagina is gradually overcome, and little by little 

1 Meigs's translation of Colombat. 



CYSTOCELE, OR PROLAPSE OF THE BLADDER. 173 

a fold is forced downward toward and through the vulva. The first 
variety is the result of a few minutes' efforts ; the second, that of 
months or even years of morbid action. Prolapse of one wall — par- 
tial prolapse, as it has been styled — is often lost sight of in view of 
the hernia of the bladder, rectum, or small intestines which accom- 
panies it. Hence cystocele, rectocele, and enterocele may be regarded 
as complications of the affection. 

Course, Duration, and Treatment. — A sudden attack of prolapse, 
being overcome by proper means and the patient kept quiet, may dis- 
appear and not return, but in that variety which occurs gradually there 
is no limit to the duration of the disease. Generally, the physician is 
not called until it has existed for a long time and become chronic. 
The most important results of the condition are prolapse of the ute- 
rus, bladder, and rectum, one or more of which are almost sure to 
ensue. 

Prognosis. — The prognosis as to cure will depend upon the degree 
and duration of the malady. It is always, whatever be its extent, sus- 
ceptible of considerable relief by surgical means, but generally proves 
incurable by those of medical character. 

Symptoms. — Should displacement of the vagina exist alone — that 
is, without creating hernia of surrounding organs — the patient will 
complain of a sense of discomfort in the vagina, with a tendency to 
bearing down as if to expel some foreign body ; a feeling of heat, ful- 
ness, and throbbing of the vulva ; a certain amount of pelvic uneasi- 
ness in walking or making any muscular effort ; and a tendency to 
become fatigued if the condition be one of aggravated character. 
Physical exploration will reveal the presence of a tumor between the 
labia, which touch will demonstrate to contain no liquid, and yet not 
to be solid in its nature. Sometimes the mucous membrane covering 
it is excoriated, ulcerated, and purple in color ; at other times it will 
be smooth, shining, tough, and covered by pavement epithelium. A 
simple vaginal prolapse of any extent is, as has been stated, quite rare. 
When it does occur it generally affects the posterior wall, but prolapse 
accompanied by hernia is more commonly found to affect the anterior 
wall, cystocele existing. Should the case be complicated by vesical or 
rectal prolapse, the symptoms just enumerated will present themselves, 
with the addition of others dependent upon disturbance of the func- 
tions of the part which forms the hernia. In one case the prominent 
symptoms will point to the bladder ; in another to the rectum ; and in 
very rare instances to the small intestines. 

As the treatment of prolapsus vaginae is, with slight modifications, 
the same for uncomplicated and complicated cases, it will be considered 
after the subject of the vaginal hernias has been discussed. 

Cystocele, or Prolapse of the Bladder. 

Cystocele, or vesico-vaginal hernia, consists of descent of the blad- 
der toward the vulva, so as to impinge upon the vaginal canal (Figs. 
62 and 03). When the anterior Avail of the vagina, which is closely 
adherent to the bladder, the base of which it in part sustains, ceases to 



174 PROLAPSE OF PELVIC VISCERA. 

afford the required assistance, the bladder, partly under this influence 
and partly under that of traction, descends and forms a small pouch 
in the vagina, This is at first very small, but gradually it increases, 
until at last it forms a decided tumor, which protrudes between the 
labia majora. The pouch thus created becomes filled with urine, 
which in the ordinary act of micturition cannot be evacuated, from 
its being contained in a species of diverticulum. This undergoes 
decomposition, free ammonia is formed, and cystitis or vesical catarrh 
is established, which annoys the patient by pain, heat, vesical tenesmus, 
and scalding in urination. Should any doubt exist as to the character 
of the tumor felt in the vagina, a curved sound or catheter may be 
passed into it through the urethra for the settlement of the question. 

It is an interesting question whether cystocele is ever the cause 
instead of the result of prolapse of the vagina, It is probable that it 
may be so in very rare cases, though such a connection between the 
two affections must be uncommon, since the former generally occurs 
in women who have borne children, and thus been exposed to influ- 
ences which tend to diminish vaginal resistance. Scanzoni : is con- 
vinced that the vesical prolapse is sometimes primary, and due to irreg- 
ular spasmodic contraction of the fibres of the body of the bladder 
while the neck remains firm. This forces the urine to the fundus, 
which dilates and undergoes displacement, 

A more correct designation of this condition would be cystocele and 
anterior colpocele, since both the bladder and the anterior vaginal wall 
are prolapsed. 

Rectocele, or Prolapse of the Rectum 
Rectocele, or recto-vaginal hernia (Figs. 60 and 61), occurs in a 
manner similar to that by which the bladder descends. The posterior 
wall of the vagina not only ceasing to give proper support to the ante- 
rior wall of the rectum, but dragging it obliquely downward, this forms 
a pouch which soon fills with fecal matter. The feces, becoming- 
hard, and, in consequence, irritating, create mucous inflammation and 
discharge, with tenesmus, obstinate constipation, and hemorrhoids. 
The tumor thus formed will sometimes equal in size a man's fist, and, 
protruding over the perineum, give some difficulty in diagnosis from its 
size and solidity. This difficulty will at once disappear upon rectal 
exploration and use of an enema of ox-gall and warm water. 

[In one instance I saw a patient confined to bed for three or four months 
from one of these sacculated accumulations of feces, under the supposition 
that cellulitis existed which by effused lymph had completely blocked up the 
pelvis. It may be supposed that such an error will rarely be met with, vet 
the case which I have just mentioned occurred to a practitioner of great 
experience and ability. — T. G. T.J 

As a rule, rectocele is annoying chiefly by the sensations of w T eight 
and dragging, and by the protrusion of the vaginal wall between the 
labia, whereby irritation from friction may take place and the vagina 
is kept exposed to outside influences. Sterility is very apt to result as 
a consequence of the non-retention of the semen. 

1 Op. cit., p. 497. 



ENTEROCELE, OR PROLAPSE OF THE INTESTINES. 175 

Enterocele, or Prolapse of the Intestines. 

Enterocele, or entero-vaginal hernia, consists in descent of a portion 
of the small intestines into the pelvis, so as to encroach upon the vagi- 
nal canal. Such a descent usually occurs in this manner : As a rule, 
no intestines are found in Douglas's pouch ; when they descend there, it 
is usually in consequence of a forward or downward displacement of the 
uterus, or some accidental motion of the patient by which the pouch is 
caused to gape. A loop of intestine which happens to be at the bottom 
of Douglas's pouch gradually stretches this serous prolongation, and, 
advancing between the rectum and vagina, pushes the posterior wall of 
the latter before it, so as to form a tumor at the vulva. In a similar 
manner it is stated that the intestine may advance between the bladder 
and uterus and depress the anterior vaginal Avail, but this must be rare, 
as authors of extensive experience assert that they have never met 
with it. 

Enterocele is not an accident likely to produce evil results unless it 
occur during labor, when strangulation may take place. Even at this 
time such a complication is very rare, for the free passage afforded the 
displaced intestine back to the abdomen will almost always preclude this 
difficulty. Dr. Meigs l relates a case occurring during labor in which the 
progress of the parturient process was checked by a large mass of intes- 
tines until he succeeded in reducing the hernia. He says, with reason, 
that in such a case strangulation or contusion was to have been feared. 

One very momentous aspect in which these hernise must be viewed 
is in relation to puncture of vaginal tumors, occurring during labor, 
for ascertaining their contents. No such explorative means should 
be resorted to without careful differentiation of vaginal hernise of all 
descriptions, and especially of that of which we have last spoken. The 
peculiar sensation to the touch of a tumor filled with air, a resonant 
sound upon percussion, the detection of peristaltic movements, and care- 
ful exclusion of all other forms of tumor which might appear under 
the circumstances, Avill serve to avoid error. When it is borne in mind 
that vaginal tumors are very near the inflated intestines, and that they 
often yield to the touch an airy sensation, it will be appreciated that 
great caution is necessary in arriving at a diagnosis. Even when the 
investigator feels positive in his diagnosis, it is always advisable to test 
the question by capillary puncture and aspiration. Should an intestine 
be punctured by the little needle employed, no evil will result. 

The following case illustrates the dangers and possibilities of erro- 
neous diagnosis in these cases : 2 

A widow get. fifty-two, mother of twelve children, the last born twelve 
years ago. A year since she suffered from prolapsus uteri, which was 
replaced. Patient presents, on examination, a swelling about three inches 
long, reddish-blue in color, protruding between the labia majora, covered 
with granulations and pus. Diagnosis — Polypus of the uterus ; operation 
for removal. After suffering severe pain in the abdominal regions for 
several hours, death ensued. Autopsy — In the pelvis was found a half 

1 Notes to Colombat on Diseases of Women, p. 211. 

2 Centralblatt far C/iir., May 8, 1879, p. SOX : Hosp. Gazette, 



176 PROLAPSE OF PELVIC VISCERA. 

pound of liquid blood. Uterus and ovaries atrophied. A portion of the 
great omentum and a piece of the transverse colon were carried away with 
the mass. In the posterior wall of the vagina was an opening about 5 cm. 
in diameter. 24 cm. of omentum and 10 cm. of the colon were excised. 

Treatment of Vaginal Prolapse and Hernia 3 . — Should the accident 
have occurred suddenly, reduction should at once be accomplished, and 
the recurrence of the displacement prevented by appropriate means. 
The bladder and rectum being evacuated, the patient should be placed 
in the knee-chest position, and, the fingers being well oiled, steady 
pressure should be exerted in coincidence with the axis of the inferior 
strait until the prolapsed part is returned to its place. In the case of 
enterocele already referred to as treated by Prof. Meigs the patient was 
placed upon the left side, and, taxis being practised, the mass suddenly 
slipped above the superior strait, into which the next uterine contrac- 
tion forced the child's head. To prevent a relapse the pelvis should 
be elevated, the patient kept perfectly quiet, tenesmus, if present, 
relieved by the use of opium, and the vagina constricted by astringent 
injections. 

But sudden cases of vaginal prolapse and hernia are very rarely met 
with. It is usually those which have slowly and gradually established 
themselves that we are called upon to treat, and these are always obsti- 
nate and rebellious. The means at our command for overcoming such 
cases are the following : 

1st. Local astringents and tonics ; 

2d. Development of retentive power of the abdomen ; 

3d. Supplementary support ; 

4th. Surgical procedures. 
The first of these may be eifectual in slight cases, but in those of 
graver character they will prove insufficient. The tone and strength 
of the vagina may be temporarily restored by the use of injections of 
large amounts of water medicated with tannin, alum, or zinc, employed 
night and morning. The patient should be sent during the summer to 
a watering-place, where sea-bathing and injections of sea-water into 
the vagina may be employed. A very excellent result will also some- 
times follow the use of vaginal suppositories containing one of the 
astringents mentioned. 

The systematic and persistent insertion every day or two of tampons 
composed of cotton or wool covered with powdered tannin and iodo- 
form, equal parts, so as to produce and maintain a constant contrac- 
tion of the vaginal canal, will in recent cases often restore the tone 
of the walls of that organ and effect a complete and permanent cure 
of the displacement. In old cases, however, no permanent benefit can 
be expected from such treatment. 

Too much stress cannot be laid upon the influence of the abdomen 
in sustaining the pelvic viscera. An impairment of its force by want 
of exercise and the pernicious habit of disabling the power and imped- 
ing the function of the diaphragm and chest-muscles by tight lacing 
and the wearing of heavy clothing is one great cause of their displace- 
ment. Improvement in this respect, by removal of the depreciating 



TREATMENT OF VAGINAL PROLAPSE AND HERNIJE. 177 



influences mentioned and recovery of lost power by appropriate exer- 
cises, is a matter of great moment. But this will be left for considera- 
tion under the head of Uterine Displacements. 

Supplementary Support. — In stout women an abdominal bandage 
with perineal pad by relieving pressure from above may accomplish a 
great deal of good when combined with complete removal of all con- 
striction and Aveight of clothing about the waist. In thin women it 
accomplishes nothing. 

The vaginal pessary, an instrument of decided value in all the 
displacements of the uterus, does little or no good here. In many 
cases no pessary which rests upon the walls of the vagina can be 
retained within the distended canal ; in others none can be found 
capable of resisting the downward pressure ; while in all increase of 
dilatation and atony is effected by them. It is true that for a time 
apparent good results from them, but the hope to which this gives rise 
is very generally delusive, and very soon they must be abandoned. 
The function of a vaginal pessary is to support the uterus, not to sus- 
tain the vagina. In some cases an exception will be found to this rule 
in Cutter's cup pessary or some similar instrument supported by an 
external attachment. Here sufficient power is afforded for support of 
the uterus at a high point in the pelvis, which mechanically puts the 
lax vagina on the stretch and prevents its prolapse, together with that 
of the bladder and rectum. This instrument will be shown in connec- 
tion with prolapsus uteri. 

An exception to this statement must be made in favor of a very 
ingenious instrument devised 
some years ago by Dr. E. C. 
Gehrung of St. Louis, which 
is shown in the accompany- 
ing cuts (Figs. 64 and 6b). 
It is used in cystocele, and, 
in our experience, is the only 

Fig. 64. 



Fig. 65. 





Gehrung's Pessary for Cystocele. 



Gehrung's Pessary for Cystocele in Position 
(diagrammatic). 



vaginal supporter which will effectually and comfortably keep up the 
prolapsed anterior vaginal wall. The method of its application is very 
simple. It rests upon the posterior vaginal Avail and pelvic floor, ana 

12 



178 PROLAPSE OF PELVIC VISCERA. 

is placed between the symphysis pubis in front and the cervix uteri 
behind. While it does not cure cystocele, it gives so much comfort to 
the patients that they continue wearing it for years, and have no 
desire for a radical cure by operation. 

Surgical Procedures. — Of these there are three which may prove 
effectual. If a ruptured perineum seems to produce the want of sup- 
port, the operation of perineorrhaphy may be all that will be necessary. 
This is described in the next chapter. Should this not be sufficient, 
colporrhaphy should be performed upon the anterior or posterior vagi- 
nal wall, as one or the other seems most at fault ; and, should even this 
not relieve the condition, the remaining wall should be likewise dimin- 
ished in extent by the same procedure. 

Almost all, except the most aggravated cases, which are accom- 
panied by great hypertrophy in the vaginal walls, will yield to these 
three procedures, alone or combined. 

Colporrhaphy or Elytrorrhaplnj} — The idea of constricting the 
vagina so as to diminish its calibre, and by this to remove the traction 
exerted by its fall upon rectum, bladder, and uterus, long ago suggest- 
ed itself to the minds of surgeons. In 1823, M. Romain Gerardin 
made the suggestion before the Medical Society of Metz, but the ope- 
ration does not appear to have been essayed, for the writer with a great 
deal of patriotic zeal states, in a subsequent essay upon the subject, 2 
that "his desire had been to put beyond controversy the origin of the 
operation, and to preserve for French surgery the priority of its con- 
ception if not of its execution." While this surgeon was felicitating 
his country upon the conception of an idea. Dieffenbach in Germany 
and Heming in England proved its practicability by absolute perform- 
ance. Dieffenbach probably operated as early as 1830, as a report of 
his having done so was published in June, 1831. In November, 1831, 
the late Dr. Marshall Hall of England published a case in which, at 
his suggestion, it had been performed by Dr. Heming, the translator 
of Boivin and Duges on the Diseases of the Uterus, with complete 
success. Subsequent to this period it was performed, with various 
modifications, by Fricke, Scanzoni, Velpeau, Roux. Stoltz, and others, 
the operation always consisting in " the removal of a band of vaginal 
mucous membrane and union of the two lips of the wound in such a 

manner as to diminish the calibre of the vagina Dieffenbach 

refers to a great number of women who were completely cured by the 

procedure Fricke out of 4 cases cured 3." 3 Judging from 

these quotations, it appears that the operation has been known and 
practised for a long time on the continent of Europe, especially in Ger- 
many. In England it had not been resorted to up to the year 1865, 
if we may judge from the statement of Dr. Sims 4 that, after a discus- 
sion upon an essav presented by himself to the London Obstetrical 
Society in that year, Mr. Spencer Wells called attention to the opera- 
tion of Mr. Heming, already referred to, with the assertion that " at 
least one case had been successfully operated upon." 

1 KoA-of or s/vrpov, " the vagina," and ()a<pq } " suture." 

2 Gazette medicate. 1835, p. 558. 

3 YHeland and Dubrisay, op. cU,, p. 533. 4 Uterine Surgery, Eng. ed., p. 319. 



COLPORBHAPHY OB ELYTBOBBHAPHY. 179 

The operation, probably for reasons which we shall mention here- 
after, had fallen entirely into disuse when Dr. Sims 1 revived it in 
1858, with certain modifications. His operation, which we shall soon 
describe, differs very essentially from that adopted by his predecessors, 
and should in justice be regarded as the parent of the numerous, 
we had almost said innumerable, modifications of it which have since 
appeared. 

It is a mischievous error to describe this operation as one performed 
for prolapsus uteri. That that displacement is one of the complications 
often existing as a consequence of prolapse of the vagina is true, but 
the operation is often necessary when vagina, bladder, and rectum alone 
are seriously involved. The traction exerted by the descent of these vis- 
cera is frequently the cause of uterine displacements of various kinds, 
and that being removed by the operation the consequent displacement 
disappears. But the student must remember that colporrhaphy is the 
legitimate surgical resource for loss of power and displacement of the 
vagina. To take a different view is to obscure the subject, and to sub- 
stitute a purely empirical for a scientific and rational arrangement. 

This error is based upon the belief that the vagina is a uterine sup- 
port, and that its prolapse allows of descent of the pelvic viscera, not 
that it drags them down by its own inherent tractile power. Some 
writers describe two operations for narrowing the vagina — one for 
the cure of prolapsus uteri, and another — both being for anterior ely- 
trorrhapy — for prolapsus vesicae ! This is surely a useless and mistaken 
technicality. Whatever supports vagina, bladder, or rectum takes away 
direct traction from the uterus, and allows other influences, the retentive 
power of the abdomen chief among them, to keep the uterus in position. 
Carl Schroeder 2 strikes the true key-note of this subject when he 
declares that u the only circumstances under Avhich we may expect a 
satisfactory result from this operation are when the vaginal prolapse 
Avas the primary one." 

Sims' 's Operation of Colporrhaphy. — The patient, being put under 
the influence of an anaesthetic, is laid upon a table upon the left side, 
as for an ordinary speculum examination, and Sims's largest speculum 
introduced. A curved sound with forked tenaculum points is fixed in 
the cervix uteri and made to cause a fold in the anterior vaginal Avail, 
as shown in Fig. 66. 

The parts being steadied by this instrument, the operator by means 
of two tenacula folds over the opposite Avails of the vagina so as to 
decide where union is to be effected. Having settled this point, the 
mucous membrane is hooked up by a tenaculum several lines above 
the meatus and cut by curved scissors. The tenaculum lifting the 
piece thus cut, and when necessary being again attached to the mucous 
membrane, the incision is carried upward, so as to cut out a strip 
extending to one side of the cervix. Then another furrow is cur in 
the same manner on the other side. 

The sound being removed and the cervix pulled down by a small 
tenaculum, the two transverse lines of denudation, shown in Fig. l>7, 
nearly uniting the two arms of the V, are made. 

1 Uterine Surgery, p. 808. '-' Dis. of Female Sexucd Organs, Am. ed., p. 208. 



180 



PROLAPSE OF PELVIC VISCERA. 




Sutures of silk are then inserted after the plan employed in vaginal 
fistulse, and by them silver sutures are drawn into position. The pas- 
sage of sutures should be commenced 
at the apex of the triangle and con- 
tinued upward. 

The after-treatment consists in 
perfect quietude in the horizontal 
posture, frequent removal of urine 
by a catheter, and the production 
of constipation by the use of opium. 
The lower sutures may be removed 
in ten days, and the upper in a fort- 
night. The patient should be kept 
/in the recumbent posture for two or 
;> three weeks, and cautioned against 

immoderate muscular effort for some 
time afterward. 
pfl Dr. Emmet, finding that the 

pouch left posterior to the uterine 
neck by this procedure was some- 
times entered by the cervix, im- 
proved the operation by extending 
the transverse denudations so as to 
make them meet. He has since 
the introduction of this procedure 
still further simplified it, in the 
following manner : At the com- 
mencement he catches up with a 
tenaculum a patch of mucous mem- 
brane at the proper distance to one 
side of the cervix, and snips this 
out with scissors. On the other 
side he does the same thing, and 
also on the posterior wall of the cervix. He then passes a wire suture 
so as to bring all these denuded points together, face to face, and twists 
the wire so as to fix them. The result is that the folding of the vagina 
accomplished by the sound, as shown in Fig. 66, occurs without the use 
of that instrument. Catching up a piece of mucous membrane on the 
vaginal fold of each side with the tenaculum, he now cuts it out, and at 
once passes a suture, and thus he proceeds, step by step, avoiding a 
great flow of blood, and opposing the abraded surfaces immediately, 
accurately, and without danger of passing the sutures so that they will 
not be symmetrical. 

As we have already mentioned, there are numerous modifications of 
this operation, but we shall mention only two more — one for elytror- 
rhaphy upon the posterior wall, or posterior elytrorrhaphy ; the other 
for the anterior operation. 

The peculiarly-shaped triangle of Sims is by no means necessary for 
this operation. Any figure which results in constriction of the vaginal 
wall will remove traction from the uterus and keep the vagina from pro- 




Operation for Anterior Colporrhaphy (Sims). 



COLPORRHAPHY OR ELYTRORRHAPHY. 

Fig. 67. 



181 




Sims's Operation : Shape of Denudation on Anterior Vaginal Wall. 

lapsing. Thus, Hegar turns the apex of the triangle up and the base 
down, while others resort to variously-shaped denudations. One of the 



Fig. 68. 




Fig. 69. 



Emmet's Operation : First Step. 



simplest for both posterior and anterior wall 
is an ovoid figure, the whole of the extent of 
which is denuded. This form dates back as 
far as Dieffenbach. It is shown in Fig. 70. 
This operation is easier of performance 
than the two preceding ones, and gives a 
stronger and more perfect union of tissues 
which is less likely to yield to pressure. When it is performed upon 




Emmet's Operation : Second Step. 



182 



PROLAPSE OF PELVIC VISCERA. 



the anterior wall the patient should lie as in Sims's operation just 
described; when upon the posterior wall, upon the back, the thighs 
flexed upon the abdomen, and the lateral walls of the vagina retracted 




Oval Denudation, with Sutures passed. 
Fig. 71. 



/ 

/ 




x 


\ ^ .,<;! 




•f 


\ -M 










W Ml 









Stoltz's Operation for Cystocele. 



by right-angled retractors held by assistants. Simon's operation of 
"posterior colporrhaphy " is only a modification of this. 



COLPORRHA PII Y OR EL YTR ORRHA PII Y. 



183 



There are two operations for narrowing the anterior and posterior 
vaginal Avails which we have practised for several years with almost 
invariable success. That on the anterior vaginal wall first came to our 
notice in a French journal, where it was ascribed to Prof. Stoltz of 
Nancy. It consists in making a circular denudation embracing the 
larger portion of the prolapsed vaginal wall, and then passing a thick 
silk suture, w T ith a needle at either end, just outside of the edge of the 
wound, beginning at the point nearest the cervix and emerging on 
either side just below the meatus urinarius. The stitch is not entirely 
buried, but is made to emerge and enter again at short intervals : the 
denuded portion, being thoroughly cleansed and rendered aseptic, is 
pushed upward toward the bladder with the sound. The two sutures 
are crossed and securely tied. The denuded portion of the anterior 
vaginal wall is thus pushed up into the bladder, and that portion of the 
passage constricted to the extent of the size of the denudation. 

Fig. 72. 




Hegar's Opei 



The great advantage of this operation is that if at the same rime 
the posterior vaginal wall and perineum are operated upon, this single 
stitch can be removed without disturbing the other parts, by simply cut- 



184 PROLAPSE OF PELVIC VISCERA. 

ting the loop just below the meatus. We have found this circular cicatrix 
to be far more lasting and less likely to separate than the longitudinal 
cicatrices following the operations already described. 

The operation on the posterior vaginal wall — that is, for rectocele 
with or without prolapsus uteri — is the one which is described by Hegar 
as original with himself. It consists in denuding a triangular strip on 
the posterior vaginal wall, the apex of the triangle being situated at 
the highest point of the rectocele, and usually within an inch of the 
cervix uteri, the two other angles at a point on each labium correspond- 
ing in height to the spot where it is desired to form the new posterior 
commissure. When all this space has been denuded the stitches are 
inserted, beginning at the upper angle. Hegar uses interrupted silver 
wire, but we have found a continuous catgut suture preferable, each 
stitch being tightened by underlooping the thread until the vaginal 
orifice is reached, when several deep sutures of silkworm gut are passed 
from the skin through the newly-formed perineum and tied outside. 
These last sutures act as stay sutures, and bring together firmly the 
sundered perineal muscles. Of course only these last sutures have to 
be removed, the catgut being absorbed. By this operation not only is 
the vagina narrowed, but the perineum is also restored to any height 
which the operator may desire. 

As a rule, it is desirable to restore the perineum in addition to and 
after narrowing the anterior vaginal wall, even though the former may 
not be very much injured. An ingenious operation for prolapsus uteri 
has been described by Leon Lefort of France, which consists of freshen- 
ing the anterior and posterior surfaces of the prolapsed vagina, each in 
two longitudinal strips, and then uniting the corresponding anterior and 
posterior strips on each side, gradually replacing the uterus as the 
sutures are tied. 

Nowadays, with our improved surgical methods and antiseptic pre- 
cautions, these plastic operations on the vagina are usually successful ; 
but, unfortunately, under the strain which is put upon the new-formed 
cicatrices by the majority of the women in whom this accident occurs, 
sooner or later the prolapsus is very liable to return. This applies 
especially to cystocele and to complete prolapsus of the uterus and 
vagina, much less to rectocele. For this reason we prefer not to operate 
on a cystocele whenever it can be comfortably retained by the Gehrung 
pessary. A rectocele, however, we alwa}^s operate upon when its size 
seems to call for active interference. The longer a woman can be kept 
in the recumbent position, and the firmer, therefore, the cicatrices are 
allowed to become before a fresh strain is put upon them, the more 
likely is the result to be permanent. The details of the operations 
for prolapsus uteri will be given in the chapter devoted to that 
subject. 



RUPTURE OF THE PERINEUM. J 85 



CHAPTER XII. 

SURGICAL MEANS ADAPTED TO RESTORATION OF THE PERINEAL 

BODY 

The pathological conditions treated of in the two preceding chap- 
ters are so directly connected with loss of power in the perineal body 
that the surgical procedure adapted to the restoration of that part very 
naturally comes next under consideration. 

We beg the reader to observe that the operative procedure about to 
be described is not limited to the cure of laceration of the perineum. 
It is appropriate to the restoration of the perineal body which has lost 
its power and function from any cause — rupture, subinvolution, senile 
atrophy, constitutional debility, or prolonged over-distension. The 
indication is to fill the triangular space created by the anterior curve of 
the posterior wall of the vagina and the posterior curve of the anterior 
wall of the rectum with a dense, resisting body, which will fit into the 
space, support the walls just mentioned, and act as the " keystone of an 
arch " which directly or indirectly sustains the bladder, the rectum, the 
uterus, and the intestines above. This is the comprehensive and broad 
view which should be taken of the operation, and upon its thorough 
appreciation and acceptance much will depend which is to follow. 

All that is said as to the importance and treatment of destruction 
of the perineum in this chapter is based upon the facts stated in Chap- 
ter X. Before reading this the student is therefore urged to peruse 
that. Without that this would be superficial and imperfect ; by its aid 
it will become much more thorough and comprehensive. In spite of 
the fulness with which the subject is dealt with there, we deem a slight 
recapitulation of salient points advisable here. In doing this we offer 
no apology for repetition of former statements, for we are advocates of 
the plan of a popular teacher of the French language, who instructs by 
" repetition sans cesse." 

Anatomy. — Proceeding in close proximity with each other toward 
the pelvic outlet, the vagina and rectum diverge at a point above the 
perineum, the one arching forward in coincidence with the pelvic curve, 
the other slightly backward toward the coccyx. In this way an irregular 
triangle is created, of which the base is the skin between the fourchette 
and anus, one side the posterior vaginal wall, and the other the anterior 
wall of the rectum. This space is filled by a body having the union 
of muscular tendons as its base, and which is itself composed of fibro- 
elastic tissue. One of its sides resting upon the rectum, the other gives 
strength, elasticity, and firmness directly to the posterior wall of the 
vagina ; while this wall, being by it pressed against the anterior or 
upper vaginal wall, sustains it and the bladder which lies upon it. 
Figs. 73 and 74 will show the relations of the perineal body and the 



.186 



RUPTURE OF THE PERINEUM. 



effect of its removal upon the vaginal walls. The anterior or upper 
wall, after its removal by rupture, lacks support and falls downward, 
prolapse of this wall occurring, with cystocele. The normal direction 
of the posterior wall is also destroyed. Instead of its arching forward, 
with a gentle curve, toward the vulva, its lower portion runs like a turned 
letter E?, to the anus. The result of this change of direction, with the 

Fig. 73. 




Perineal Body perfect; both Vaginal Walls sustained. 

coincident loss of support from the strong elastic perineal body, is to 
create a sagging forward, and soon prolapse of this wall follows that 
of the anterior, and uterine displacement is a consequence. 

It may with some justice be remarked that Fig. 74 represents the 
perineal body not simply exhausted, but split through, as can only be 
done by laceration. It is true that in other conditions of loss of power 
there is an appearance of a perineum left, but it is the semblance of a 
departed power, and the diagram must in such cases, to a certain extent, 
be regarded as schematic, referring to absence of function rather than 
of tissue. 

When a woman with a normal perineum is placed upon the back, 
and the finger of the examiner is passed into the vagina, as it passes 
over the perineal body it will be firmly pressed against the upper vagi- 
nal wall. Upon the withdrawal of the finger the separated walls will 
be observed to come in contact at once by the rising of the posterior 
wall. If the perineal body have lost its power, no such upward pres- 
sure is found to exist, and the vaginal walls are discovered to be in 
less close contact. 

After operation for restoration of the destroyed perineum an exami- 
nation of this kind should be made. If the upward pressure of the 



RUPTURE OF THE PERINEUM. 
Fig. 74. 



187 




Perineal Body removed by Rupture ; both Vaginal Walls robbed of Support, 

perineal body is found to be sufficient to bring the posterior in contact 
with the anterior vaginal wall, the object of the operation has been 

Fig. 75. 




Perineum improperly Repaired; Perineal Body not restored to Place; Vaginal Walls not 

sustained. 

attained. If it do not so, botli walls will lack support, in spite oi' the 



188 RUPTURE OF THE PERINEUM. 

fact that the superficial perineum, the base of the perineal triangle, has 
been united and appears perfect. The latter result will deceive the 
patient, and may deceive the surgeon, with false hopes. The former 
will alone give future immunity from the dangers of vaginal prolapse 
and its consequences. 

Those influences which destroy the power of the perineum and ren- 
der it incapable of its important functions are the following : 

Constitutional feebleness ; 

Prolonged over-distension ; 

Senile atrophy ; 

Subinvolution ; 

Laceration. 
All these, with the exception of the last, have been considered with 
sufficient fulness in Chapter X. ; laceration requires more careful 
study here. 

It being now understood that the repair of a perineum, the power 
of which has been destroyed from any of the causes mentioned, is to 
be conducted upon exactly the same principles as those which apply 
to the operation for laceration, we shall use this accident as a means 
of illustrating it, and confine our remarks to it during the rest of this 
chapter. 

Varieties of Perineal Laceration. — All cases may be classed 
under two heads : Complete and Partial Rupture. 
These include the following degrees of destruction : 

Superficial rupture of the fourchette and perineum, not 
involving the sphincters ; 

Rupture to the sphincter ani ; 

Rupture through the sphincter ani ; 

Rupture through the sphincter ani and involving the recto- 
vaginal septum. 
Complete rupture presents such serious discomforts as a consequence 
that partial rupture is by many viewed as a trivial circumstance. So 
it is by comparison, but so likely is it to be followed by prolapse of 
one or both vaginal walls that it should never be undervalued. As 
soon as such prolapse occurs uterine, vesical, and rectal troubles 
become almost inevitable. 

The evils resulting from partial rupture are by no means insignif- 
icant, but they are more remote and more tolerable than those which 
follow complete. When the sphincter ani is torn through, and still 
more markedly when the rectal wall is ruptured, incontinence of feces 
and rectal gases occurs to such an extent as to embitter the life of the 
unfortunate patient. The consequences of rupture of the perineum 
may thus be presented : 

Subinvolution of the vagina ; 

Prolapsus vaginae, with cystocele or rectocele ; 

Prolapsus uteri ; 

Incontinence of feces and intestinal gases ; 

Prolapsus recti. 
The first three of these may result from both varieties of rupture, 
complete and incomplete ; the last two attend only the former. Even 



RUPTURE OF THE PERINEUM. 189 

when the two passages are laid into one, it is sometimes surprising to 
see how little the patient may suffer ; but generally under these cir- 
cumstances her condition is truly deplorable. Fecal matters and gases 
pass without control, and the uterus, vagina, bladder, and rectum tend 
so strongly to descend that exercise, muscular efforts, or tenesmus pro- 
duces weariness, pelvic pain, and traction upon the broad ligaments. 
In some instances so great is the disturbance of function that the 
unfortunate woman finds herself an object of disgust to her associates 
and even of loathing to her husband. 

Subinvolution of the vagina is rarely alluded to as a consequence 
of rupture of the perineum ; but we see the two conditions too often 
coexistent to regard it as a mere coincidence. " The muscular walls 
of the vagina," says Savage, "are not separable into coats or layers. 
Two-thirds of the thickness of the vagina, varying from 2-3 lines 
above to 5-6 below, are made up of this muscular portion : the inner 
third consists of a dense, cellular lining membrane inseparably united 
to it." The elastic, contractile elements of this canal are identical in 
structure with uterine fibre, and development occurs in them as in 
those of the uterus under the stimulus of gestation. A retrograde 
metamorphosis likewise affects them subsequent to labor. As this pro- 
cess is often interfered with in the uterus by rupture of the cervix, so 
is it in the vagina by rupture of the perineum. Let any one appeal to 
his own experience for the frequency of subinvolution of the vagina 
as a concomitant of rupture of the perineum. It may be objected 
that the latter often results from difficult and particularly from instru- 
mental delivery, which may produce both conditions. An examina- 
tion into the histories of cases will refute this ; the result is often pro- 
duced when the labor has been very rapid and unaided. It may again 
be suggested that prolapse of the vagina, a consequence of the rupture, 
excites excessive growth in its walls ; but the two things coexist where 
perineal rupture has not resulted in vaginal prolapse almost as often 
as where it has done so. 

Causes. — The power of the perineum may be destroyed by a number 
of influences, for which the reader is referred to Chapter X. of this 
work. For laceration of the perineum there are but two causes — first, 
by far the most common, parturition ; and second, some accidental 
injury, such as the passage of large tumors, a fall upon a sharp object, 
etc. 

Minute details upon this subject, and upon means which should be 
adopted for prevention, will be found in works upon obstetrics. 

Prognosis. — In an incomplete case of slight character, where the 
fourchette and only a small portion of the perineal body are involved, 
no evil usually results. Laceration of this character and to this extent 
is the rule in first labors, and not the exception. It requires no inter- 
ference, and is so insignificant in consequence that it is not included 
under the subdivisions which we have mentioned. Even the first and 
second degrees of laceration which we have tabulated are often pro- 
ductive of no evil, and may, unless careful inspection be made, pass 
unrecognized by both physician and patient. But this is the exception, 
and not the rule. The third degree is always an accident o\' gravity, 



190 RUPTURE OF THE PERINEUM. 

while the fourth represents the most serious form of the condition. The 
greater the injury, the less likely will be spontaneous recovery, and the 
more probable the complications and results which have been mentioned. 

Natural History of Perineal Laceration. — It is the general impres- 
sion, and one which we formerly shared, that any laceration which does 
not entirely sever the sphincter ani may unite by first intention without 
surgical treatment, and that none which converts the two passages into 
one will do so. Even, however, when the rupture has been complete, 
it has been asserted that spontaneous cure has taken place. Observa- 
tion at the bedside, however, has led us to question whether union by 
adhesion of the lips of these wounds ever occurs spontaneously. Very 
certain are we that in our own experience we have never seen one do so. 
Let the limbs be bound together ever so closely, the inevitable passage 
of lochial material between the cut surfaces prevents union by first 
intention. Repair is effected by granulation, and is often very good, 
but it is never perfect. We are not prepared to say that the statement 
is absolutely and universally true, but we believe it to be so as a general 
rule, that a lacerated perineum left to nature for repair is never after- 
ward as perfect as it was before the occurrence of the injury or as it 
usually is after proper repair by surgical means. 

How, then, is it, it may be asked, that so many women who suffer 
from laceration of the perineal body do not suffer from the conse- 
quences which have been mentioned ? First, because, if the lacera- 
tion does not interfere with vaginal involution, it often does no harm, 
or at least not for many years, when its connection with displacements 
is entirely forgotten ; and second, because the imperfect repair effected 
by granulation is commonly sufficient to answer all purposes. 

We are fully aAvare that many will be found who will positively 
affirm that they have seen even lacerations in the third and fourth 
degrees entirely repaired by first intention. " False facts," says Cullen, 
" are more dangerous than false theories." This we strongly suspect — 
though, as we have stated, Ave cannot assert — to be one. The ostium 
vaginae just after delivery is, in its over-distended and always slightly 
lacerated condition, with folds of redundant vagina pressing down upon 
it, a most deceptive part. We have ourselves often been deceived as to 
serious laceration just after delivery, and we have frequently seen 
others similarly misled. A prolific field is thus open for error to the 
superficial and inexperienced examiner, who, having mistaken a slight 
laceration for one of aggravated character, and finding that repair has 
been effected by nature, asserts in future that he has known spontaneous 
recovery even after most extensive destruction of the perineum. 

Should the case really be a serious one, however, and the practitioner 
one who believes that nature will in all probability repair the accident 
and restore the perineal body to its important functions, a golden oppor- 
tunity will be lost, and the patient in all likelihood remain a sufferer in 
consequence. 

Time for Operation. — Formerly, authorities differed widely upon 
this point, some urging immediate action, some advising delay until the 
effects of parturition have entirely passed away, while others compro- 
mise the matter by giving preference to the plan of waiting a few days 



TIME FOR OPERATION. 191 

only. As already stated, at the present day no conscientious obstetri- 
cian would hesitate a moment to close every perineal laceration immedi- 
ately after the expulsion of the placenta whenever the rent seems to 
him sufficiently large to demand repair. An exceedingly rare excep- 
tion might be made in cases where the woman is so exhausted by the 
labor as to forbid even the slightest prolongation of her sufferings, or 
where the parts are so bruised as to offer no chance of immediate union. 
The worst cases of the accident with which we meet generally follow 
instrumental or manual delivery, and when the discovery of its occur- 
rence is made the patient will usually be in a profound anaesthetic 
sleep. Every operator should be prepared, under such circumstances, 
to attempt repair of the injury, for if he succeed the patient will be 
saved much suffering, while failure will not in any wise depreciate her 
condition. For this reason no case of obstetrical instruments should be 
considered complete which has not in it needles and sutures for per- 
formance of this operation. We have always resorted to immediate 
operation, and have never had occasion to regret our action. There 
are three circumstances which tend to defeat the success of immediate 
operation : First, it is often performed by one not habituated to its 
performance, and, being practised upon a woman who, having just been 
delivered, is exposed to the clanger of post-partum hemorrhage, and 
surrounded by anxious friends, it is likely to be finished too hastily; 
second, the lochia! discharge, constantly passing over the lips of the 
wound, is very likely to enter and prevent union ; third, the operator 
having been taught to regard the perineum as the superficial layer of 
tissues intervening between the fourchette and anus, closes this by 
correspondingly superficial sutures, leaves the upper portion of the 
perineal body open, creates a pouch for the accumulation of putrefying 
materials, and leaves the anterior vaginal wall and bladder without sup- 
port in the future. 

Our advice and practice with regard to this point are decidedly to 
give the patient the benefit of the doubt and to close the rupture at 
once. If failure follow, however, never, unless there be some special 
reason for so doing, attempt another operation before the results of 
parturition have entirely passed away. This will not be before the 
lapse of two months from the time of delivery: just after delivery 
there is a reason for operating which has passed away in a fortnight. 

As Ave have elsewhere already remarked, it is our conviction that 
a very large number of cases of uterine disease take their origin in the 
lying-in chamber, and a large proportion of these are unrepaired cases of 
lacerated perinea. When immediate operation becomes the rule of 
obstetric practice, the number of cases of disease thus occurring will 
at once and very decidedly diminish. 

But the full results of immediate operation will never be exhibited 
until the obstetrician studies the anatomy of this part, aud learns how 
to approximate its entire divided surface by sutures carried up to the 
highest point at which solution of continuity has occurred. 

Formerly we employed the old-fashioned method of introducing the 
first suture at the lower angle of the rent, and the last one at the pos- 
terior commissure, of course always passing them as deeply as possible, 



192 



RUPTURE OF THE PERINEUM. 




so as to include the whole of the torn surfaces. This plan necessitated 
the use, in a deep laceration, of probably from four to six sutures, and 
had the disadvantage of allowing blood to flow over the wound while it 
was being closed. It was therefore possible that a perfect cleansing of 

the wound might accidentally 
Fl «. 76. not take place. Of recent 

years, however, we have 
adopted a much better plan, 
as follows : "We take a strong 
curved needle, at least three 
inches in length, thread it 
with strong sublimated silk, 
and pass it from a point cor- 
responding to the upper mar- 
gin of the rent on one labium 
downward and backward above 
the upper angle of the lacera- 
tion in the posterior vaginal 
wall, and out again at a spot 
corresponding to the point of 
entrance on the opposite la- 
bium, keeping the suture 
carefully concealed. The 
wound having been thor- 
oughly cleansed by irrigation 
or sponging with a 1 : 5000 
bichloride solution, this single 
suture is securely tied ; in this 
way the floor of the vagina is 
at once closed, and the remain- 
ing perineal wound shut off 
from contamination by blood 
oozing from the uterus. Usu- 
ally, now not more than two 
other comparatively superficial 
stitches have to be passed, care 
of course being taken that the deep portions of the wound are included 
and approximated when the sutures are tied. This operation is very 
easy of performance, requires but a few minutes, and is well borne 
even by very much exhausted patients. If for some reason only the 
first suture can be inserted and tied, a very good perineum would prob- 
ably result, since the closure of the roof of the vagina would permit 
spontaneous union of the rest of the wound. We certainly think that 
by this method more than three-fourths of perineal lacerations are 
healed by first intention. We have even treated cases of complete 
laceration in this manner with fair success, although we admit that 
the proportion of good results is much smaller than in partial rupture. 
The sutures are usually removed between the fourth and seventh days, 
when they will have begun to cut, and, whether union has taken place 
or not, are no longer of anv use. 




Suturing of Freshly-lacerated Perineum. 



SECONDARY OPERATION. 193 

Treatment of Cases which have Cicatrized. — The operation which 
is now generally adopted in these cases, and which has received the 
name of perineorrhaphy, consists in vivification of the edges of the 
lips of the wound and their approximation by sutures. Although the 
accident for which this procedure is instituted was described by the 
ancients, no surgical means of cure were ever advised for it until the 
time of Ambrose Pare. He advised the suture, and was followed in its 
use by his pupil Guillemeau. Subsequently it was employed by Dela- 
motte, Saucerotte, Trainel, Noel, and others. Dieffenbach employed it 
successfully, adding to the operation oblique lateral incisions involv- 
ing the skin and areolar tissue, for the purpose of relieving tension 
upon the parts brought together by suture. 

About the year 1832, Roux of Paris obtained the most brilliant 
results from the operation, and probably its elevation to the position 
of a reliable surgical procedure was due more to his achievements than 
to those of any other individual. He employed the quilled suture, and 
cured by it four out of the first five cases operated upon. Although 
such success was obtained in France at this period, we find English 
writers as late as 1852 and 1853 l doubting the efficacy of sutures and 
advising that assistance should be limited to aiding the efforts of nature. 

Among the older operators within our own recollection by whom 
great advances have been made in this operation are Baker Brown in 
England ; Verneuil, Demarquay, and others in France ; Langenbeck 
and Simon in Germany ; and Sims, Emmet, Agnew, and others in the 
United States. But within the last decade even these methods have 
become more or less obsolete, and newer and more perfect operations 
have been devised by Hegar, Martin, and Fritsch in Germany ; Le 
Fort, Richet, and Doleris in France ; Lawson Tait in England ; and 
Emmet (new method) in this country. This operation, which in former 
years was shrouded in so much mystery and encumbered by such com- 
plicated and misleading explanations as to be but imperfectly understood 
by the majority of operators, has, through the labors of the men just 
mentioned, become one of the simplest achievements in gynecological 
surgery. Within our own recollection the late Prof. Simon of Heidel- 
berg considered the cure of a complete perineal laceration a rather 
marvellous accomplishment, and he devoted much time and labor to 
the completion of his somewhat complicated method of operation ; but 
nowadays, while failures do still occur after the operation for complete 
laceration, they are decidedly in the minority ; in fact, the operation 
has now become one that is very generally performed, even by men 
who make no pretence to being specialists in gynecology ; and there is 
no reason why this should not be the case, since, if the anatomy of the 
parts is carefully studied and correctly understood, it requires no very 
special surgical skill to do the operation properly and successfully. 
The old quilled suture, the cutting of the tissues alongside of the 
perineum, the division of the sphincter ani (except occasionally after 
complete perineorrhaphy), the dissecting of flaps from the neighboring 
cutaneous surfaces, and some other features, have long since become 
obsolete. In the following pages we shall describe the methods used 

1 Baker Brown, Surgical Diseases of Women. 

13 



194 RUPTURE OF THE PERINEUM. 

by us and by several of the other gentlemen named above, because we 
think it our duty to place before the reader not only our own practice 
and experience, but also those of other operators whose methods may 
differ from ours. As no two cases need necessarily be alike, so may 
every individual laceration require a distinct operation by itself. To 
the ingenuity of the operator must be left the choice of one or the 
other method, or the advisability of combining the distinctive features 
of several operations. 

We have retained in this chapter substantially the description and 
figures given in our last edition, because we did not see how we could 
alter the description in conformity with the newer methods of opera- 
tion without completely changing the sense of the chapter. The old 
description has seemed to render the plan of operation so intelligible to 
the reader that we have hesitated to alter it, for fear of obscuring the 
meaning. We therefore continue to show the operation as we used to 
perform it, and as many still perform it, but in addition we give the 
descriptions and diagrams of newer and perhaps better operations. 

Preparation of the Patient. — The general health should be care- 
fully investigated. If it be bad the operation should be delayed, and 
the patient put upon tonics and placed under the best hygienic circum- 
stances. For a week before operation the bowels should be kept lax 
by some mild cathartic, in order that after that time cure shall not be 
jeopardized by the coming down of scybalse which have not been 
removed by a cathartic given twenty-four hours before operation. 
This point is one of a great deal of moment, and should not be over- 
looked. In cases of complete rupture it is better even to give a fort- 
night to the fulfilment of this indication. A compound cathartic or 
compound aloetic or rhubarb pill may be given every twelve hours, or 
a saline cathartic at the same intervals. Free alvine evacuation, not 
hypercatharsis, is what is required. During this time the vagina 
should every night and morning be thoroughly syringed out with warm 
water to remove secretions and quiet local irritation. 

Instruments and Appliances Needed. — These will consist of a long- 
handled curved scissors ; a bistoury with narrow blade : a tooth-forceps 



Fig 




Mm. 
B.TIEMANi* - C0- 



Thomas's Tooth-Forceps. 
Fig. 78. 




Curved Scissors. 



and tenaculum ; one dozen small sponges (size of a walnut) fixed in 
handles ten inches long ; artery-forceps ; silk ligatures ; and straight 
darning needles threaded with silk, which is double and tied at the 



OPERATION FOR PARTIAL RUPTURE. 195 

eve of the needle by as small a knot as possible. A basin of water 
should be in readiness to receive the bloody sponges, and a pitcher. 
bucket, or other reservoir at hand to supply more when this is to be 
changed. The instruments should be kept immersed in carbolized 
water, with which the parts should be freely bathed. 

Fig. 79. 




Emmet's Scissors, sharply curved. 



Operation for Partial Rupture. — It is a matter of great surprise 
to us that no distinct separation should be made by many of the older 
writers between the descriptions of operations for partial and complete 
rupture. The first is a procedure in which the merest tyro should 
succeed ; the second is one of the most delicate and uncertain opera- 
tions in gynecology, in which even the most skilful may fail. We feel 
sure that evil has arisen from confounding a simple and a difficult pro- 
cedure, and shall make a wide difference between them. 

The operation for partial rupture has for its sole object the restitu- 
tion of the perineal body. That for complete rupture has for its main 
object the restoration of the power and functions of the sphincter ani. 
After the main object of the second operation has been attained, that 
of the first should claim attention. 

Before describing these operations we would say a few words upon 
division of the sphincter ani. [I have operated a great many times for 
rupture of the perineum, and cannot recall a case of final failure ; thus 
far I have never cut the sphincter. My experience, confirmed by that 
of many others, leads me to indorse Dr. Savage's statement, that " the 
success of operations for the closure of perineal lacerations is obviously 
not promoted by the division of the superficial anal sphincter." — 
T. G. T.] 

[I do not agree with this opinion, so far as it applies to complete 
laceration, since I am quite sure that by cutting the sphincter pos- 
teriorly, after closing the rent, and inserting a rubber tube, I have not 
only prevented the distressing symptom of rectal tenesmus, but have 
also permitted free escape of flatus, thus ensuring the union of the 
sphincter muscle. — P. F. M.] 

Let the operator keep clearly in mind the shape and dimensions of 
the body which he is about to restore. It is a triangle with apex 
above and base below. Two surfaces of this shape are to be vivified 
and held face to face by sutures. That is the whole operation. 

First Part of the Operation. — The patient, dressed for bed, should 
be placed upon a table before a window admitting a strong light, in 
the position for lithotomy, and put under the influence of ether. Four 
assistants will be serviceable, although three would answer the purpose. 
One of these should administer the anaesthetic, one should hold each 



196 RUPTURE OF THE PERINEUM. 

knee, and the fourth should attend to the duty of handing the required 
instruments to the operator and washing the sponges as they become 
bloody. The assistants, lifting the feet from the table and flexing the 
thighs, so that the edges of the tibire will be horizontal, should hold 
the knees clasped under the arms and steady the feet with the hands 
of the same side, while the unoccupied hands of the other side retract 
the labia and expose the ruptured part. These directions should be 
observed by the assistant holding the right knee ; he who holds the 
left should do so with the right arm, clasping it with this and retract- 
ing the labium with the right hand, while with the left he sponges 
the wound with sponges held in long handles, which do not cause his 
hand to obstruct the operator's view. It will at first appear that it 
would be difficult for one assistant to do all this. Let him who thinks 
so try it, and he will find that it is not so, and that such arrangement 
of his aids will be greatly to his advantage. This operation, like so 
many others in surgery, often fails, or at least drags heavily in its 
progress, from the want of a sufficient number of assistants, to each of 
whom is allotted an especial duty. 

All being now ready, the index and middle fingers of the two assist- 
ants who hold the knees are fixed upon the labia by the operator, and, 
the degree of traction which they are to practise being regulated, the 
operation is begun. 

Seizing the tissue just above the anus with tooth-forceps or a tenac- 
ulum, a strip of mucous membrane is removed from the posterior vagi- 
nal wall and from the original site of the perineal body upward as 
far as it is proposed to extend to the rectal side of the triangular denu- 
dation to be created on each side. 

The rectal side of the new perineal triangle then is created by denuda- 
tion of the posterior vaginal wall. If the base or rectal side of this trian- 
gle does not involve the posterior vaginal wall, what does it involve ? 
This was the original site of the perineal body. Its anterior or vaginal 
side was originally vagina, and the posterior vaginal wall now prolapses 
and usurps the place of this body. 

In reference to the organization of the present operation of perineor- 
rhaphy, or at least as regards all its essential features, it may be stated 
that the credit of making it a colpoperineorrhaphy and rendering it a 
remedy for rectocele belongs to Baker Brown. A reference to his w T ork 
will put this beyond question, as he represents the operation in a 
diagram with this descriptive statement, "Operation for Rectocele." 
His operation combined all that is essential in that which is now, with 
little modification, generally accepted. Since his publication of it no 
one has materially altered it except Marion Sims, who performed the 
important function of stripping the procedure of certain superfluities, 
like section of the sphincter and the use of quills, which were not 
merely useless, but absolutely hurtful. 

We have now formed what is to be the base and line of union of 
two triangles, which meet upon the furrow just created. Now, catching 
up the tissue on the inner side of one labium majus, about midway 
between meatus and anus, another furrow is cut extending down to the 
anal origin of the first furrow, and another is then carried from the 



OPERATION FOR PARTIAL RUPTURE 



197 



point selected on the labium backward to the upper or vaginal extrem- 
ity of the basic furrow. A triangular space, covered by mucous mem- 
brane, mapped out by three bleeding fur- 
: -vs, will be left, as shown in Fig. 80. 

v. * - furrow extending from anus up the 
vagina (the rectal side) ; C B, furrow extend- 
ing from anus to point midway up labium 
majus (cutaneous side); B A, furrow extend- 
ing from point on labium to vaginal extremity 
of rectal furrow (vaginal side). Now the tis- 
sue in the unabraded triangle D is removed 
by tenaculum and scissors, as little tissue as 
possible being cut away, and a bleeding tri- 
angle is left. The opposite side is similarly 
treated, and the result is two such triangles 
placed base to base upon the line C A. The 
doubling over of these upon each other, and 
the securing them in contact by suture, con- 
stitute the second part of the operation, as 
shown in Fig. 81. 

In performing the first part of the operation we very commonly begin 
on one side, and cut successive strips across until the whole surface is 
pared; but the method which we have mentioned simplifies the pro- 




One of the Bleeding Triangles 
which are to be Created. 



Fig. 81. 




The Two Bleeding Triangles about to be United. 



cedure, and after adopting it once for the complete understanding of 
the operation the operator may afterward do otherwise. 

This part of the operation may be performed by the knife, but it is 
done more expeditiously and with less hemorrhage by the scissors, as 
Emmet lias so justly pointed out. E. W. Jenks of 'Detroit has pro- 
posed another method of denudation, which consists in the introduction 
beneath the mucous membrane of a pair of sharp-pointed scissors, by 



198 RUPTURE OF THE PERINEUM. 

which, without for a moment removing them, he by rapid snips separates 
the membrane from its attachment and removes it with great rapidity 
and little loss of blood. All the denudation done is effected in this 
manner. ■ We have employed this method on several occasions, but 
have abandoned it on finding that, while apparently bloodless, on 
removing the flap of vaginal wall thus separated the hemorrhage was so 
profuse as to require a number of arterial ligatures, and the sutures had 
to be passed much more deeply than when superficial strips of mucous 
membrane were removed, one by one, until the whole surface was 
denuded. 

The whole surface having been pared, the operator stops and care- 
fully examines to see if any arteries are spouting and if any undenudecl 
surfaces still remain. If he find the former he twists them, and, if 
necessary, ties them with very delicate catgut ligatures, which he cuts 
short ; if the latter, he catches them with the tenaculum, and with the 
bistoury cuts them away. 

The first step of the operation is now finished. The operator should 
not hasten to the second, for the tissues should be exposed for a while, 
that he may be assured against hemorrhage. It is not necessary, how- 
ever, to wait until hemorrhage has ceased before applying the sutures* 
since superficial oozing is checked, and even spurting arteries are com- 
pressed, by the tying or twisting of the sutures. 

Second Part of the Operation. — Now, taking in the needle-holder 
a round, curved, or straight needle, about two and five-eighths inches 
long, which will cause less hemorrhage than the needle with cutting- 
edges, armed with a doubled silk thread, giving a loop about eight or 
ten inches long, he inserts it opposite the lowest external angle of the 
vivified triangle, which would be a little above the level of the anus, 
and makes it pass across the middle of the united bases of the triangles, 
over the rectum, and emerge at a corresponding point on the opposite 
side. This suture is nowhere visible within the vagina, for it lies 
imbedded in the tissues lying over the rectum. It may be passed by 
one sweep, or, if this prove difficult, may be drawn out at the middle of 
its course and reinserted. The suture is twisted at its extremities and 
left in position, and, another being taken, it is inserted above the first, 
and made to pass through the tissues at a higher point of the vivified 
surface. Guided by the finger in the rectum, it is kept imbedded in 
the recto-vaginal septum and emerges at a point on the other side 
corresponding to that of entrance. 

This, like its predecessor, we are in the habit of concealing in the 
tissues, so that after its passage it is nowhere visible within the vagina. 
We believe that an imbedded suture excites much less irritation on the 
denuded surface and acts less like a seton upon it than an exposed one. 
In this way sutures of silk are passed, and by them those of silver are 
immediately drawn into place, about one-third of an inch apart, and 
inserted at a quarter or half an inch from the edges of the wound. All 
these are concealed from view, except the last one or two, which should 
pass under the upper angles of the triangles, and, catching up the vaginal 
tissue at the highest point of the denudation, should bring them all 
together. 



OPERATION FOR PARTIAL RUPTURE. 



199 




Shows Surface denuded and Sutures in Position. 



Of late years we have used silkworm gut almost exclusively for this 
operation, threading it directly into the needle. It is less painful than 
wire, and less likely to 
produce suppuration than 
silk. Of course it has 
been properly asepticized, 
as described on p. 62. 
It must be removed at the 
proper time precisely like 
silk or wire, as it is not 
absorbed. 

At each side of the pe- 
rineal triangle thus formed 
two pockets may be created 
in which putrid materials 
may collect. To avoid this, 
great care should be taken 
to conceal the sutures, es- 
pecially at these points. 
Denudation should like- 
wise be most carefully prac- 
tised there. 

For the details as to 
the method of drawing 
the wires into place and 
twisting them the reader is referred to the article on Vesico-Vaginal 
Fistula. After the plan there described he twists them one after the 
other from beloAV upward. If it appear necessary, superficial sutures 
of catgut are then passed between the deep ones to approximate 
the cutaneous surface more completely. 

The wire sutures should not be cut short, but left about two inches 
long, then twisted together and secured by a small piece of India- 
rubber tubing, after a plan suggested by Emmet. The patient is then 
put to bed ; the knees are loosely bound together ; the dorsal or lateral 
decubitus preserved; the urine drawn by catheter every six hours or 
voided spontaneously by the patient if able, a tepid vaginal irrigation 
being given after each voluntary urination. As the bowels have been 
thoroughly moved, according to directions, before the operation, there 
is no need of disturbing them for the first two or three days afterward ; 
but on the third, or latest on the fourth, day gentle laxatives should be 
given, either calomel in one-tenth grain doses every half hour until ten 
or fifteen have been taken, then to be followed by drachm doses of 
Rochelle salts in hot water every half hour until from four to eight 
have been given, or a compound licorice powder or a mixture of cream 
of tartar, sulphur, and sulphate of magnesia, equal parts, may be 
administered, if necessary aided by a warm enema, and the bowels 
thus be freely and gently moved. At least every other day a move- 
ment should be secured by means of a mild laxative or an enema, until 
about the seventh to the tenth day, when the sutures should be removed. 
This early moving of the bowels is a radical departure from the old- 



200 



RUPTURE OF THE PERINEUM. 



time custom of constipating them and not having them moved until 
after the removal of the sutures. Its introduction is chiefly due to the 
late Prof. Simon of Heidelberg, whom we saw use this method about 
twenty years ago. It is much superior to the old method of constipa- 
tion, which was far too frequently followed by a rupture of the new 
cicatrix during the passage of the hard scybalous masses. 

Operation for Complete Rupture. — Complete perineal laceration 
always involves rupture to a greater or less extent of the anterior wall 
of the rectum. If rupture of the bowel extend for more than from 
one inch to an inch and a half above the upper edge of the sphincter 
ani, it is better to close it by a primary operation consisting of vivify- 
ing its edges and uniting them down to the anus. After union of these 
parts closure of the perineum may be practised. If the bowel be not 
injured above an inch and a half from the sphincter, one operation will 
suffice to close the whole. We would not be understood as making this 
a dogmatic rule, but merely one which approximates the line of con- 
duct which we deem best. 

The sole object of the operation for partial rupture is restoration 
of the perineal body. The objects of the operation for complete rup- 
ture are — first, restoration of the sphincter ani muscle to all its power 
and functions ; second, closure of the rectal opening ; and third, resto- 
ration of the perineal body. What constitutes the main object in the 
first operation is the least important of those striven after in the second. 



Fig. 83. 




Figs. 83-86.— Diagrammatic Representation of Union of Ruptured Sphincter Ani (Emmet). 

The operator must then appreciate that mere closure of the rent in the 
genital fissure is not what is desired. He may gain this and not bene- 
fit his patient in the least, for incontinence of feces and gases may 



OPERATION FOR COMPLETE RUPTURE. 



201 



Fig. 87. 



continue. Success involves always complete union of the ends of 
the severed muscle and complete closure of the rent in the bowel. To 
secure these the ends of the muscle, spread out and expanded, must be 
curled up and approximated, and the recto-vaginal septum must be 
drawn up and united to them. With these facts in view, clearly defined 
and appreciated, the difficulties of the operation greatly diminish. To 
no one are we so much indebted for their demonstration and illustration 
by practical results as to Dr. T. A. Emmet, who in 1873 wrote a valu- 
able paper upon the subject, giving a clear exposition of the peculiar 
action of this accident upon the sphincter ani, and of the best method 
of restoring it to its normal shape and functions. 

Let Fig. 83 represent the perfect sphincter; Fig. 84 will show it rup- 
tured and spread out, with the point of insertion and exit of the needles. 
The dotted line shows the course of the metallic sutures imbedded in 
the tissue. It will be seen that the remaining recto-vaginal wall is a 
fixed point, and that as the wire is twisted the ends of the muscle are 
elevated, and the three points approach each other, as shown at C. As 
the twisting goes on these points come nearer and nearer together, as 
seen in Fig. 85, until at last they unite as shown in Fig. 86. 

Should the first needle be inserted and drawn out above the end of 
the broken muscle, as shown in B B, Fig. 84, 
the tissue at this point will be approximated, 
and the ends of the muscle brought close to- 
gether, but absolute and complete union will not 
have been attained and loss of function will still 
exist. The first suture is the important one, 
and must catch the ends of the broken and ex- 
panded muscle so as to lift them upward into 
contact with each other and with the recto- 
vaginal septum. 

In vivifying the parts before insertion of 
the needles two lateral triangles representing 
the perineal body split in two are denuded, 
and the line of denudation is prolonged back- 
ward along the edge of the recto-vaginal sep- 
tum. The border of the rectal mucous mem- 
brane at the extremities of the broken muscle, 
as far as the upper end of the rent in the 
bowel, is the guide for doing this. 

Fig. 87 is a schematic diagram showing 
the ruptured bowel, the expanded muscle at 
its anal extremity, the insertion and exit of 
the needles, and the course (dotted lines) of 
the imbedded sutures. The line of denuda- 
tion is marked out by the course of these 
sutures. 

The rectal rent presents itself to the opera- 
tor as an imperfect isosceles triangle, apex 
above and base below. The two lateral borders of this arc 
to be vivified. The two basic angles are on a lower 




Diagrammatic Sketch of 
Course of First Suture for 
Union of Ruptured Sphinc- 
ter Ani. 



the 
plane 



>arts 

than 



202 



RUPTURE OF THE PERINEUM. 



that of the apex, and are less fixed in their position. As the three 
angles are acted upon by the constricting influence of the encircling 
suture as this is gradually twisted, the two movable basic angles are 
elevated to the plane of that of the apex, while the latter is by trac- 
tion drawn down to meet them. Coincidently, the denuded sides of 
the triangle are of course approximated, and thus the rectal opening 
is completely closed. 

To sum up this part of the subject, the rule for passing the first 
suture consists in the introduction of the needle as low down as the 
lower edge of the anus. From this point it passes upward through 
the recto-vaginal septum, completely encircles the rectal rent, and 
comes out alongside of the lower edge of the anus on the opposite 
side. 

Let the reader refer to Fig. 84 and he will appreciate that a suture 
which takes this course, like the string at the mouth of a bag, puckers 
the open parts, draws them into apposition, and controls the action of 
the sphincter. The two conditions which we have to fear as sources of 
failure after this operation are — first, recto-vaginal fistula, and second, 

non-union of the sphincter. This 
Fig. 88. method to a great extent secures us 

against both. The subsequent steps 
of this operation are the same as 
those of that for partial rupture. 

AVe have in a large experience 
with this operation failed a certain 
number of times. As it is from our 
past failures that we must learn to 
avoid failure in the future, we shall 
strive to give the reader the benefit 
of our experience. In several of our 
cases perfect union was obtained, 
but the rectum was found, in spite 
of the fact that in both cases cathar- 
sis had been kept up for a week, 
filled with large, hard, scybalous 
masses. This created violent tenes- 
mus, and destroyed the newly-formed 
perineum. 

In several other cases a large 
rectal plug of soft inspissated fecal 
matter had been left in place in spite 
of thorough catharsis, and its neces- 
sary removal by the fingers or a spoon ruptured the united extremities 
of the sphincter muscle, leaving the perineum whole. 

In one case the nurse in using the syringe for a rectal injection 
unquestionably passed its nozzle repeatedly between the lowest suture 
and that just above it, leaving a central opening in the perineum, 
which constituted a recto-perineal fistula, the sphincteric union remain- 
ing perfect. 

Upon the experience thus obtained we have predicated the follow- 





Purfaee denuded in Complete Perineal 
Rupture, and First two Sutures in Posi- 
tion. 



OPERATION FOR COMPLETE RUPTURE. 203 

ing rules of practice, which we invariably observe and strongly recom- 
mend : 

1st. When about to operate for complete perineal laceration give 
one entire week to complete evacuation of all scybalous masses from 
the intestinal canal. This tract, it must be remembered, is twenty-five 
feet long, and keeps fecal masses stored up in it for months. Do not 
practise hypercatharsis, but let the patient have two medicinal evacu- 
ations in every twenty-four hours. This may be done by giving one 
compound rhubarb or compound cathartic pill every eight, twelve, 
or twenty-four hours, according to the patient's susceptibility to 
catharsis. 

2d. During this time feed the patient freely upon animal food and 
animal broths, wheat, potatoes, and other nutritious articles of diet. 

3d. During the first four days after operation sustain her entirely, 
though thoroughly, upon strong animal broths alone, avoiding milk 
especially, which creates scybala of hardened casein. The reliance 
upon milk for avoidance of scybala is a mistake. 

4th. Do not disturb the bowels for two days after the operation. At 
the end of that time they should be acted upon by a gentle laxative or 
enema. 

5th. If a rectal tube be employed, let it be one of small size. 

6th. Should an enema be used, let the physician himself administer 
it, unless the capacity of the nurse be above suspicion. Remember that 
the rectal tube should be carefully passed backward, so as not to inter- 
fere with the recto-vaginal septum. 

Every surgeon must admit that no detail is too insignificant for his 
personal attention which is capable of turning the balance in favor of 
or against the success of an operation which he has performed. 

Formerly it was thought necessary in cases of very deep perineal 
laceration extending one or more inches up the recto-vaginal septum to 
perform the operation in two steps — first, closing the recto-vaginal rent, 
and several weeks later restoring the perineum ; but it is chiefly owing 
to the genius of Simon of Heidelberg that we have found it possible 
to complete both these steps at one sitting. His method of operation 
was peculiar, tedious, and from our present standpoint unnecessarily 
complicated. He first denuded the whole area of laceration, then intro- 
duced a row of silk stitches into the recto-vaginal septum, which were 
knotted one after the other in the rectum, the sutures being carried 
out of the anus ; secondly, he did the same with the vaginal surface of 
the rent, knotting the stitches in the vagina; and thirdly, he closed the 
cutaneous wound by a number of stitches. There were thus three sets 
of stitches — rectal, vaginal, and perineal. The rectal and vaginal were 
allowed to slough out ; the perineal were removed about the tenth day. 
His successes were very good, as we ourselves have had opportunity to 
observe. This operation may properly be called the ideal operation for 
complete laceration of the perineum and recto-vaginal septum, since ir 
approximated on strictly surgical principles each of the parts which it 
was intended to unite. However successful this operation may have 
been and always Avill be in a certain number of cases, there are some 
instances in which the recto-vaginal suture will fail to secure a perfect 



204 



RUPTURE OF THE PERINEUM. 



union, and a fistula will result, usually just within the posterior com- 
missure. In order to avoid this very unfortunate occurrence, which is 
perhaps mostly quite unavoidable, some operators have vivified and 
closed the recto-vaginal rent by means of catgut sutures, one set being 

tied in the rectum, the other set 
in the vagina, and when complete 
union had been achieved have 
closed the now incomplete lacera- 
tion in the manner already de- 
scribed or by one of the methods 
still to be reported. In our expe- 
rience, however, the necessity for 
this double operation is exceed- 
ingly rare. 

Emmet's New Operation for 
Lacerated Perineum. — At the 
meeting of the American Gyne- 
cological Society in 1888, Dr. T. 
A. Emmet described an operation 
for lacerated perineum which has 
attracted a great deal of attention, 
and which in the opinion of the in- 
ventor is destined to remain one of 
the established operations in gyne- 
cology. Dr. Emmet very correctly 
took the view that in order to com- 
pletely restore the anatomy and 
functions of the female perineum 
it was necessary to bring the fibres 
of the pelvic fascia and of the torn 
muscles of that body directly in ap- 
position, and so retain them. This he claimed the previous operations 
did not perform. Dr. Emmet denudes two elliptical surfaces in either 
lateral furrow of the vagina, beginning at the posterior commissure in 
the median line and extending up variably from two to three inches. 
The limits of these two lateral denudations are the internal border of 
the posterior commissure, the lowest caruncle of the hymen on either 
side, and the crest of the rectocele in the centre. The edges of each 
lateral wound are then united by sutures which are carried deep into 
the furrow and entirely under the raw surface, so as to pick up the 
separated fibres of the pelvic fascia when first one side and then the 
other is sutured. There remains only a very shallow slit of mucous 
membrane in the median line to stitch together, which is done with silk. 
To remove the stitches it is only necessary to elevate the anterior vagi- 
nal wall with Sims's speculum. 

Theoretically, this operation is exceedingly plausible, and would be 
the ideal one if it actually lifted up and retained the separated fibres of 
the perineal body, but in practice, unfortunately, it, in our opinion, fails 
to do this. It restores most perfectly the calibre and relations of the 
posterior vaginal wall, but it leaves the vulvar orifice gaping as before, 




Simon's Operation for Complete Laceration 
of the Perineum. (Sectional view, dia- 
grammatic.) 



OPERATION FOR COMPLETE RUPTURE. 



205 



and therefore does not respond to the requirements of a perfect opera- 
tion for perineal laceration. It is a beautiful operation for rectocele, 
but that is all. 1 This operation, it should be distinctly understood, is 
not applicable to complete laceration. 

Flap-splitting Operation for Lacerated Perineum. — As already 

stated, we have described the 
Fig. 90. above operations because, in 

part, we have been very suc- 
cessful with them in past 
years, barring a certain num- 
ber of — as we then thought 




Emmet's New Operation for Lacerated Perineum. 

unavoidable — failures, and because we think that there are still many 
members of the profession who will prefer them to a newer operation, 
with which we have become very much enamored during the last tow 
years (P. F. M.). The operation to which we refer is that first rein- 
troduced by Lawson Tait, and recommended after him by Saenger, 



1 It is but fair to say that Dr. Emmet claims that the failure to restore the perineum 
and posterior commissure to their normal condition is the fault of the operator, and 
is due to the fact that the area of denudation is not sufficiently broad in the centre, 
and is not carried high enough up on the sides. 



206 



RUPTURE OF THE PERINEUM. 



Martin, and others. It differs essentially from the methods already 
described, in that no tissue whatever is removed, but the result is 
achieved by simply splitting transversely and perpendicularly the 
surfaces thereafter to be united. This method is perfectly appli- 
cable, in our opinion, to complete lacerations of the perineum, but it 
is equally useful in incomplete rupture. It may briefly be described 
as follows : The patient being placed, after the usual preparations, 
in the lithotomy position, the recto-vaginal septum is split from side 
to side, beginning in the median line, by means of a pair of sharp- 
pointed scissors. If now the laceration is an incomplete one, the 
incision is carried up on either side to the upper border of the peri- 
neal cicatrix, the depth of the wound upward being not more than 



Fig. 92. 



Fig. 93. 





Flap-splitting Operation for Incomplete 
Laceration of Perineum (lines of in- 
cision) (diagrammatic). 



Flap-spitting Operation for Complete Lacer- 
ation of Perineum (lines of incision) 
(diagrammatic). 



from a quarter to a half inch. The upper or vaginal flap is then drawn 
upward by means of a tenaculum or forceps, the lower or rectal flap 
downward by similar means, and the sutures are then passed, carefully 
concealed throughout, from the left side of the patient to the right, 
beginning at the point nearest to the anus, a straight or very slightly 
curved needle being used. In our opinion it is best to introduce the 
sutures just outside the edge of the wound, emerging at the same spot 
on the other side. Lawson Tait has recommended passing them just 
within the edge of the wound, but we do not think this method as good, 
because the edges of the skin are not brought into close apposition. All 
the sutures having been introduced, they are tied, and the almost inevi- 
table puckering of the posterior vaginal commissure is corrected by short 
interrupted catgut sutures, so as to ensure complete closure of the 
wound at that point. 



OPERATION FOR COMPLETE RUPTURE. 



207 



In complete laceration the operation differs only in one point — 
namely, on either side of the transverse incision which splits the recto- 
vaginal septum a downward and backward incision is carried, which goes 
just beyond the edges of the separated sphincter ani muscle. The flaps 
upward and downward are held apart precisely as already described, 
and the first suture, beginning from behind, is inserted just outside and 
below the edge of the torn sphincter ani, and brought out exactly at 
the same spot on the opposite side. After this the stitches are intro- 
duced precisely as in the incomplete laceration. 

The advantages of this operation are twofold : First, the rapidity 
of operating, which in our opinion is not a matter of so very great 

Fig. 94. 




Flap-splitting Operation for Lacerated Perineum (Appearance of Wound and introduction of 
Sutures for both Varieties). 



importance as it has beeu made to seem by its ardent advocates. The 
operation can be performed either in incomplete or in complete lacera- 
tion within ten minutes, but if we wish to secure perfect skin-union it 
is necessary to introduce a certain number of superficial catgut sutures 
into the perineum or along the vagino-perineal commissure: and the 
better apposition we secure, the smoother and more perfect the line of 
union achieved. Therefore, we have found that it is better to procure 
perfect adaptation than it is to do a hasty operation. 

Second, chiefly as regards complete lacerations, we have found the 
results to be very much more certain in securing a perfect restoration 



208 



RUPTURE OF THE PERINEUM. 



Fig. 95. 



of the function of the sphincter ani and in preventing the formation of 
recto-vaginal fistula than with the methods which we have described 

above, and with which Ave 
had been more or less suc- 
cessful for many years. The 
shortest time in which we 
have performed this operation 
for complete laceration has 
been seven minutes, the long- 
est forty minutes, the latter 
being a case where the opera- 
tion had been twice attempt- 
ed before by other operators 
and by other methods with- 
out success, and where the 
subject was exceedingly 
fleshy and a number of 
spurting arteries required 
ligation. The result, how- 
ever, was in every respect a 
perfect one. 

Very recently an inge- 
nious method of introdu- 
cing the sutures has been 
described by Dr. Clement 
Cleveland of New York, 
the nature of which will be 
seen by studying the accom- 
apidity, and a more thorough 




Cleveland's Suture for Lacerated Perineum. 



panying diagram. He claims for it ease 
coaptation of the wounded surfaces. 

Dangers and Evil Results of Secondary Perineorrhaphy. — If we 
were asked the question if this were a dangerous operation, we should 
unhesitatingly reply, No. It is no more dangerous than any ordinary 
cutting operation whereby certain organs, vessels, nerves, etc. are injured 
in any other part of the body, and under our present aseptic rules 
certainly no accident should result from a perineorrhaphy. Still, we 
remember having in past years seen a case of fatal tetanus, and quite 
recently of fatal septicaemia, follow this operation ; but we believe that 
with the experience afforded us by these two accidents, only one of 
which occurred in our practice, we can avoid their repetition. Of 
course, formations of pus along the track of the suture, oedema, or 
sloughing of parts of the wound, would require removal of the offend- 
ing sutures and treatment on surgical principles. One of the most 
disagreeable results following a perineorrhaphy is the formation of a 
recto-vaginal fistula. If this does not close spontaneously — as it is 
very apt to do if the bowels are kept regular, thorough cleanliness is 
observed, and the fistula is not too much interfered with — the only rule 
of treatment is to split the new perineum down to its original degree 
of laceration, and to reunite the surfaces by one of the methods already 
described. The attempt to cure a recto-vaginal fistula by paring and 



MALFORMATIONS AND DISEASES OF THE HYMEN 209 

suturing its edges will mostly prove a failure, whether it he undertaken 
from the vagina or rectum, or both. A perineo-vaginal fistula is usually 
of no consequence, and will close on cauterization ; if not, it may be 
left alone. A recto-perineal fistula is, however, more annoying, and 
will probably have to be treated upon the principle of the usual anal 
fistula. 

Usually a perineorrphaphy should not be followed by a rise of temper- 
ature ; if such does occur, it is well to inspect the edges of the wound 
for oedema or the ischio-rectal fossae for tumefaction, cellulitis, and 
abscess, which should be treated, if found, on general surgical princi- 
ples. Nowadays we expect a secondary perineorrhaphy to be in ninety- 
nine cases out of a hundred a complete success. Still, we are willing 
to modify this statement somewhat when referring to operations for 
complete laceration, in which the special difficulty of the operation, the 
trouble of moving the bowels effectually and easily, and perhaps unfore- 
seen complications, may cause a certain number of failures, chiefly con- 
sisting in incomplete union of the sphincter or a small recto-vaginal 
fistula, the whole number not aggregating more than 10 per cent. In 
operations for incomplete laceration we have no failures to record. 

When a rectocele and an incomplete perineal laceration are present 
in the same subject, it is not necessary to perform two different ope- 
rations at separate intervals, since by means of Hegar's operation, 
described under Rectocele, both conditions can be cured in one sitting. 

Various kinds of sutures are employed by different operators : some 
use catgut exclusively, others silk, others silkworm gut, and others 
again silver wire. We, for our part, prefer catgut for sutures which 
are buried or difficult of removal, as on the posterior vaginal wall, and 
of late years silkworm gut for the closure of the external perineal wound. 
We find the latter much less painful than the silver wire, which we 
employed for many years before the silkworm gut became popular, and 
we think it less irritating and less liable to cause suppuration than silk ; 
still, this may be a matter of opinion, and we do not pretend to being 
infallible on this point. 



CHAPTER XIII. 

MALFORMATIONS AND DISEASES OF THE HYMEN. 

Anatomy and Physiology. — The hymen is a small, usually crescentic 
membrane, which separates the vulvar cleft from the vaginal canal, and 
may be considered as the portal to the vagina. Anatomists are still in 
doubt as to whether the hymen is formed by a centrifugal growth of 
skin after the completion of the vaginal canal, or by a perforation of 
the closed lower end of Muller's ducts. The latter view would seem to 
the more plausible one. 

There are many conformations of the hymeneal membrane, all oi' 
which may be perfectly normal and physiological. Thus wo may have 
u 



210 



MALFORMATIONS AND DISEASES OF THE HYMEN 



a hymen shaped like a crescent, both horns tapering away toward the 
vestibule (Fig. 97) ; or the membrane may encircle equally the whole 



Fig. 98. 







Fig. 99. 



Fig. 100. 





Varieties of Hymen. 

vaginal orifice, its opening being in the centre, the usual form (Fig. 
96); or, instead of one central opening large enough to admit the 
point of the index finger, the hymen may be perforated by a number 
of small openings (Fig. 100); again, it may be a large, fleshy, very 
distinct menbrane, or it may be only a slender band encircling the 
vaginal opening. Its edges may be so tense as to tear even under the 
very slightest efforts at dilatation, and again it may be so elastic as to 
readily admit two fingers, and even an average penis, without laceration. 



MALFORMA TIONS. 



211 



Muscular fibres, nerves, and blood-vessels are found in the hymen, 
and usually its rupture is attended by pain and a certain amount of 



bleeding. 



Malformations. 



1. Absence of the Hymen. — The hymen may be entirely wanting 
or only a trace of it be present, even though the remainder of the 
genital organs are perfectly normal. 

2. Imperforate Hymen. — The hymen may be congenitally imper- 
forate, the child being born without the usual hymeneal opening. This 
is of no consequence until the menstrual function begins, when of course 
the escape of the monthly discharge of blood cannot take place. The 
girl has the symptoms of menstruation every four weeks, but no blood is 
seen. She complains of increasing pain with each monthly return, and 
gradually the abdomen begins to enlarge. Usually by this time the 



Fig. 101. 



Fig. 102. 





Retention of Menstrual Blood in Vagina and Uterus by Imperforate Hymen (diagrammatic). 

attention of the mother is called to the sufferings of her daughter, and 
a physician is consulted. If the symptoms of menstruation have per- 
sisted for several months, probably enough blood will have accumulated 
not only to distend the uterus, but also the vagina, and to cause a 
bulging of the imperforate hymeneal membrane. The diagnosis is very 
easily made by the history, the symptoms, and the subjective signs. 
Above the symphysis pubis will be found a globular, tense, very slightly 
fluctuating body, corresponding in outline to the distended uterus, and 
a more or less distinct wave of fluctuation will be transmitted from the 
fundus uteri to the protruding surface at the vaginal orifice. The 
treatment is obvious, and consists in making an incision into the imper- 
forate membrane, so as to allow of the escape of the retained blood. 



212 MALFORMATIONS AND DISEASES OF THE HYMEN. 

Authorities differ as to whether it is best to make a large opening and 
permit the blood to escape rapidly and freely, or a small incision which 
will permit only a gradual discharge of the retained fluid. The reason 
for making a small opening is that it was feared that a sudden discharge 
of the blood would not permit the uterus to contract gradually, but 
might excite sudden contraction, which would force the blood through 
the Fallopian tubes into the peritoneal cavity. This fear, however, is, 
in our opinion, not well grounded, since under our modern methods of 
antisepsis it has been found perfectly safe to make a large incision, or 
indeed excise enough of the hymen to permit the blood to escape 
rapidly. The whole genital tract is then carefully irrigated with a solu- 
tion of 1 : 10,000 bichloride, and the usual bichloride gauze dressing 
applied over the vulva. The uterus generally contracts rapidly enough 
to ensure against any septic absorption. Of course it is important to 
prevent the admission of air into the uterine cavity, and therefore 
digital or specular examinations should be avoided at the time of, or 
soon after, the operation. An ice-bag should be kept on the abdomen 
for several days after the evacuation. If a distended tube has been dis- 
covered on bimanual palpation, it is well to evacuate the uterine con- 
tents slowly in order to prevent a possible rupture of the tube, 
which might be caused by forcible contractions of the uterus, hoping 
that the blood in the tube will gradually follow that escaping from the 
uterine cavity proper. In any case it is well to avoid hastening the 
escape of the blood by compressing or rubbing the uterus through the 
abdominal walls. 

3. Unyielding Hymen. — The hymen may be so fleshy and so tense 
that it resists rupture even after prolonged and repeated attempts at 
sexual intercourse. 

4. Hymen with Double Opening. — The hymeneal opening may be 
divided into two sections by a band of tissue extending from the centre 
of the upper margin to the lower. Probably this band is but the 
remains of the lower septum of Muller's ducts, which was not absorbed, 
as was the remainder of the septum. We have seen several such cases, 
which came under our notice chiefly on account of the obstacle to 
coition formed by the central band, which, after double ligation, was 
removed with scissors (Fig. 99). 

5. Fimbriated Hymen. — Instead of having the usual smooth border, 
the hymeneal opening may be surrounded by a well-marked fringe, the 
so-called hymen fimbriatus (Fig. 98). 

6. Distensible Hymen. — A few cases are on record in which the 
hymen was so exceedingly distensible as to permit not only coition, but 
also the birth of a child at term, without rupture. Therefore, while 
the rupture or absence of the hymen would usually mean that either 
defloration or parturition had taken place, still, it must not be forgot- 
ten that the membrane may be congenitally absent, may have been 
torn by instrumental manipulations, by masturbation, or by the passage 
of some large body other than a child — namely, a tumor — through the 
vaginal orifice. The hymen can, therefore, not be considered absolutely 
without reserve to be a sign of virginity. 

Injuries to the Hymen. — The hymen is usually torn during first 



VAGINISMUS. 213 

coition, the laceration generally being situated posteriorly or to one side 
or the other. Unless a woman has borne a child at term, however, the 
flaps of the torn hymen can be readily readjusted, and it will then be 
found that usually none of the hymen has been actually destroyed ; but 
after a confinement the facts are different, for then it will be found 
that the posterior portion of the hymen has usually completely disap- 
peared, having been absorbed during the normal involution following 
childbirth, or having sloughed away in consequence of the pressure 
exerted upon it during that event. Schroeder first called attention to 
this fact, which is of some importance in determining, especially in 
medico-legal cases, whether a woman has borne a child or not. 

Occasionally, during first coition, the physiological rupture of the 
hymen may produce so much hemorrhage as to place the woman's life 
in danger and necessitate the introduction of sutures or the application 
of styptics. Several such cases have come to our notice, and one 
instance of death from the hemorrhage is recorded by Wachsmuth. 1 

Several instances are on record in which the hymen, its normal 
border being unusually tense and resistant, had been torn from its 
attachment, remaining adherent only at one small portion. In these 
cases coition took place usually underneath the partly separated hymen, 
and was then unattended by pain; but occasionally the penis would 
accidentally enter the normal opening of the hymen, and great pain 
would of course be produced by the fruitless efforts to penetrate the 
orifice. These symptoms induced the patients to seek medical advice, 
when the cause of the dyspareunia was discovered. The treatment of 
course consisted in ligating and severing the small point of attach- 
ment of the hymen. 

Neoplasms of the Hymen. — Two cases of cysts of the hymen are 
reported by Winckel of Munich, which were accidentally discovered 
and removed with scissors. There are really no new growths of the 
normal hymen on record, but the torn membrane is liable to a peculiar 
pathological affection which has given rise to the symptoms described 
under the general name of vaginismus. 

Vaginismus. — By the term vaginismus is understood a painful and 
usually spasmodic contraction of the vaginal orifice on the slightest 
approach of the male organ, which more or less effectually prevents 
the performance of the function of coition. In many instances the 
cause of this spasmodic contraction is due to the presence of peculiarly 
and exquisitely sensitive remains of the torn hymen. These so-called 
carunculse myrtiformes, instead of being quite insensitive, are so ten- 
der to the slightest touch that the muscles controlling the vaginal 
orifice involuntarily contract, and even prevent the entrance of the 
examining finger. To sight, the hymeneal caruncles may not appear 
either enlarged or diseased, but if they are examined microscopically 
after removal they will usually be found to contain an excessive num- 
ber of enlarged nerve-filaments, and to be in fact neuromata. 

In some other cases these hypersesthetic caruncles are absent, and 
nothing is found to account for the vaginismus but an eroded and exqui- 

1 See Munde, "Hemorrhage from Laceration of t lie Hymen," Boston Med. and Surq. 
Joum., May 14th, 1885. 



214 MALFORMATIONS AND DISEASES OF THE HYMEN. 

sitely tender vaginal orifice. In those cases where perfect coition has 
not yet taken place, and where the hymen is still unruptured, the 
membrane may be found inflamed and exquisitely tender in conse- 
quence of the repeated attempts at intromission. Finally, in perhaps 
the least number of instances, there are found neither acutely sensitive 
hymeneal caruncles nor an inflamed and eroded vaginal orifice to 
account for the difficulty in coition. The explanation must be that in 
consequence of either ineffectual or only partly effectual attempts at 
intercourse, or because the wife objects to the act, each attempt puts 
her into a condition of nervous apprehension ; the mere approach of 
the male produces a nervous excitement, which results in an involuntary 
spasmodic contraction of the constrictor cunni and levator ani muscles. 
Then, again, there may be certain lesions of the vaginal orifice which 
may account for the pain and fear of intercourse. Thus, urethral 
caruncles, fissures of the vaginal orifice, fissure of the anus even, may 
be the cause of the dyspareunia. 

The late Professor Hildebrandt of Koenigsberg described a pecu- 
liar form of vaginismus in which the obstacle was situated within the 
vagina, instead of at its orifice, and was due undoubtedly to a spas- 
modic contraction of the levator ani muscles. In this form either only 
partial insertion of the penis was possible, the obstruction being near 
the middle of the vagina, or withdrawal of the organ was temporarily 
prevented after completion of the act. 

Treatment. — The treatment naturally will differ according to the 
nature and cause of the complaint. When sensitive hymeneal carun- 
cles are found to be the cause, the only way of curing the patient is to 
put her under an anaesthetic and remove the caruncles with curved scis- 
sors, or, if this seems necessary, pare off the whole of the posterior half 
of the hymeneal membrane, and divide the superficial fibres of the bulbo- 
cavernosus muscles at either side of the median line to a depth sufficient 
to relax their tension, carrying the incisions from half an inch in the 
vagina to the border of the skin. This method of treatment was first 
instituted by J. Marion Sims, who was among the first to recognize the 
pathology of the disease. The vaginal orifice is then thoroughly stretched 
by means of a trivalve or quadrivalve speculum, and a large-sized glass 
tube is inserted and retained until the wound has healed. At first the 
tube should be removed only in order to allow the patient to pass 
water or when her bowels are evacuated ; after the wound has healed, 
and until all danger of a recontraction of the vaginal orifice has 
passed, the tube should be worn at least an hour every day. At that 
time it can readily be introduced and removed by the patient herself. 
The wound once healed, attempts at coition should be permitted ; but 
it is advisable at first to recommend the inunction of the orifice with a 
10 per cent, cocaine ointment, or a suppository of one drachm of the 
same ointment may be inserted into the vagina a few moments before 
the expected intercourse. 

When erosion of the vaginal orifice seems to be the sole cause of 
vaginismus, a different plan of treatment should be followed. First 
paint the eroded surfaces thoroughly with a solution of nitrate of silver 
of 20 grains to the ounce ; then direct that a pledget of lint smeared 



TREATMENT. 215 

with a 10 per cent, cocaine ointment be kept constantly between the 
labia, so as to prevent friction, and let the patient bathe the parts and 
irrigate the vagina frvvo or three times a day with a tepid solution of 
lead-and-opium wash of the strength of about four to six tablespoon- 
fuls to a pint of water. The nitrate-of-silver application should be 
repeated every third or fourth day until the redness and tenderness of 
the parts have entirely disappeared ; then an attempt should be made 
to introduce as large a cylindrical speculum as the patient can bear 
without severe pain, this attempt being renewed with a larger size 
every day until one of at least two inches diameter can easily be 
inserted. Then a dilator as above described should be given to the 
patient for daily use until painless coition is practicable. The same 
treatment, with the exception of the dilatation, applies to the cases 
where the hymen is unruptured, but the vaginal orifice is eroded and 
tender. In aggravated cases of this kind, however, especially where 
the membrane is thick and has resisted attempts at rupture before, it 
may be necessary either to incise it in various places or to excise it 
entirely, and then proceed with the use of the dilator as already 
described. 

In those cases where the vaginismus seems to depend entirely upon a 
nervous source, attempts should be made to overcome the fear of the 
patient by moral persuasion, by recommending abstinence from sexual 
intercourse for some time, and by using either cocaine or opium sup- 
positories per vaginam before coition is attempted. Sims has found it 
necessary in very severe cases to give an anaesthetic and permit sexual 
intercourse under its influence. This, however, will probably be sel- 
dom necessary. Usually, local narcosis and dilatation as above described 
will result in overcoming the spasmodic contraction. We have met 
with several cases in which the vaginismus seemed to depend upon a 
spasmodic contraction of some of the lower fibres of the levator ani 
muscles, and have cured the cases by dividing these fibres with the knife 
under anaesthesia, and then proceeding with dilatation as described. 

One case has recently come to our notice in which we were con- 
sulted because the husband had been unable to effect an entrance into 
his wife's vagina since marriage, two months before. The lady had last 
menstruated shortly before her wedding, and during the past month had 
suffered from morning nausea. An examination revealed an unruptured 
hymen, which admitted only the index finger, and was torn on attempt- 
ing to insert two fingers. The uterus was found enlarged to the size of 
pregnancy at about two months, and we were obliged to admit that we 
had before us one of those extremely rare cases of impregnation with- 
out intromission of the penis (P. F. M.). 



216 



VAGINITIS. 



CHAPTER XIV. 

VAGINITIS. 

Definition and Synonyms. — The mucous membrane lining the vagina 
is subject to inflammatory action, which receives the name of vaginitis. 
It is the same disease which by certain authors has been described 
under the titles of blennorrhoea and blennorrhagia. 

Anatomy of the Vagina. — The vagina is a canal formed of strong 
muscular elements and lined by mucous membrane. At its upper 
extremity it is attached to the cervix uteri, with which it unites at a 
variable point, but usually midway between the os internum and os 
externum. This canal consists of three coats : First, an outer coat, 
formed of fibrous and elastic tissue ; second, a middle coat, formed of 
unstriped muscular fibre and fibre-cell, which are subject like the same 
structures in the uterus to great hypertrophy during utero-gestation ; 
and, third, an inner coat or lining mucous membrane, composed of con- 

Fig. 103. 




Microscopical Section through Vagina of a Child a few days old : V, vaginal wall ; Pp, papilli- 
form projections, from the wall of which secondary processes extend, both covered with 
thick, plaster-like masses of epithelium (Hartnack, from Beigel). 

nective tissue and elastic fibre, and covered over with squamous epithe- 
lium. The third extends to the fourchette ; the first and second spread 
out at the upper portion of the perineum, making the perineal septum, 
and attach themselves to the ischio-pubic rami. Its general form has 
been aptly likened, by Dr. Savage, 1 to that which would be assumed 
by a flexible tube if shortened to nearly half its length by a cord passed 

1 Op. cit. 



VAGINITIS. 217 

from end to end through one of its sides. The ridge thus formed is called 
the anterior column of the vagina, and marks the vesico-vaginal septum. 
It is about two inches long, while the posterior Avail — the posterior col- 
umn, as it is called — is twice that length. The anterior column, or 
cord which shortens the vagina, puckers its investing mucous membrane 
and throws it into folds or rugae, which run transversely toward the 
posterior column. This mucous membrane is studded with papillae, 
which are covered by pavement epithelium. The papillae of the vagina, 
which were first fully described by Dr. Franz Kilian, were regarded by 
him as having for their function the transmission of sensation. He 
represents them as being thread-like and filiform. 

Much discussion has occurred among anatomists as to the presence 
of muciparous glands between the folds of the vaginal mucous mem- 
brane, some asserting and others as positively denying their existence. 
The researches of Huschke, Jarjavay, Jamain, Farre, and recently of 
Von Preuschen, enable us to accept their existence as an undoubted 
fact, though they are limited, according to the last-named observer, to 
the upper portion of the canal. The vagina may then be said to be 
lined by mucous membrane which is covered by epithelium, and thrown 
into folds which are studded by projecting filiform papillae, between 
which lie occasional muciparous follicles. 

Varieties of Vaginitis.— Vaginitis assumes three forms, which differ 
from each other sufficiently to require separate investigation. They are 
denominated as follows : 

Simple vaginitis ; 

Specific vaginitis ; 

Granular or papillary vaginitis. 
Prof. Hildebrandt of Germany has recently described another variety, 
which he styles " adhesive," for the reason that its chief characteristic 
is to produce adhesion between the vaginal walls and the vagina and 
cervix. It may occupy the whole of the vagina: the mucous mem- 
brane bleeds readily ; and the discharge is thick, creamy, and san- 
guinolent. It occurs very frequently in elderly women, and is then 
known as senile vaginitis. 

Simple Vaginitis. 

Definition. — This variety of vaginitis consists in inflammation of 
the mucous membrane of the vaginal canal from some cause other than 
gonorrheal contagion. 

Varieties. — It may exist in acute or chronic form, either of which 
types may appear originally or be the result one of the other. The 
acute form may be excited by some special cause and rapidly pass into 
the chronic ; or, originating as a low grade of inflammation, the disease 
may at any time take on the characters of virulence and acuity. Two 
subdivisions of simple vaginitis, the recognition of which at the' bedside 
constitutes an important point, are primary and secondary. Sometimes 
the disease exists as a primary lesion, but very commonly it depends 
upon the excoriating properties of a fluid discharged by the mucous 
membrane of the uterus. Under these circumstances no treatment 



218 VAGINITIS. 

addressed to the vaginal surface will effect a cure, for even if the dis- 
order existing there be removed, it must inevitably return so long as 
the cause which originally produced it remains. 

Causes. — In the great majority of instances this affection, more par- 
ticularl}' in its chronic form, depends upon a discharge from the uterus, 
to which it is secondary. It may, hoAvever, arise from any of the fol- 
lowing exciting influences : 

Exposure to cold and moisture ; 
Injury from pessaries or coition ; 

Disordered blood-states, as those of phthisis and the exanthemata ; 
Retained and putrefying secretions ; 
Chemical agents ; 
Parturition. 
After matrimony the acute form is not unfrequently excited, and in 
prostitutes, whose occupation involves an abuse of sexual intercourse, - 
it is quite common. 

A bit of sponge or other substance which retains the natural secre- 
tions, left in the vagina until putrefaction occurs, will often induce the 
affection, and three of the most virulent cases that we have ever seen 
were caused by contact of a solution of chromic acid with the vaginal 
walls in making an application to the uterus. 

Pathology. — At the commencement of the disease the mucous 
membrane of the vagina becomes highly vascular and its arterioles are 
distended. There is a rapid moulting of epithelium, so that abrasions 
often exist, and at times follicular ulcerations and diphtheritic deposits 
make their appearance. Sometimes, though rarely, the epithelial lining 
of the vagina is thrown off entire, constituting a cast or mould of the 
canal very similar in character to the dysmenorrhoeal membrane which 
is occasionally expelled from the uterus. 

In very severe cases the inflammatory action passes down into the 
submucous tissues, and a true phlegmonous process is established which 
may result in abscess. For a period varying from fifteen to thirty hours 
after the inception of the disease the natural secretion of the part is 
checked ; then pus of acrid and offensive character pours forth freely, 
which in a week or ten days is replaced by muco-purulent material. 
This discharge is found to consist of serum, large numbers of epithelial 
cells, pus, blood-globules, and an infusorial animalcule called the Tri- 
cJiomonas vaginalis by Donne, who first described it. By some 
the last has been regarded as ciliated epithelium separated from the 
uterus, but it is probably an animalcule which exists in vaginal mucus 
of unhealthy character. Donne at first regarded it as characteristic 
of specific vaginitis, but subsequently renounced the view. 

Symptoms. — Acute vaginitis manifests itself by the following symp- 
toms : 

A sense of heat and burning in the vagina ; 

Aching and weight at the perineum ; 

Frequent desire for micturition ; 

Profuse purulent discharge of offensive character ; 

Violent pelvic pain and throbbing ; 

Excoriation of the parts around the vulva. 



SIMPLE VAGINITIS. 



219 



Fig. 104. 




Epithelium in all Stages of Development 
in Simple Vaginitis. 220 diameters (T. 
Smith). 



In the chronic form the disease shows the same symptoms, though 
with much less severity. In very mild cases only a slight itching or 
burning sensation is experienced, with discharge of the leucorrhoeal 
matter. 

Physical Signs. — When the inflammation is acute the labia are found 
swollen and tense, the mucous membrane of the vaginal canal red and 
covered with pus, and the animal heat 
very much increased. Introduction 
of the linger produces great pain, and 
often cannot be tolerated. As the 
labia are separated a flow of fetid muco- 
pus is discharged. If the canal be 
explored by means of the speculum, 
its surface will be found congested, 
while at numerous points abrasions, and 
perhaps follicular ulcerations, will be 
noticed. The inflammatory appear- 
ances of the vagina will be seen to 
have extended to the cervix uteri, and 
very generally from the os will be found 
to hang a plug of mucus secreted by the 
irritated, or even inflamed, Nabothian 
follicles. 

Prognosis. — In its acute form it 
usually runs its course in about two 
weeks. In the chronic form it lasts for an indefinite time, often subsid- 
ing into ordinary vaginal leucorrhoea, or rather into a state of which 
this is the only prominent symptom. 

Differentiation. — Simple vaginitis may be confounded with 
Gonorrhoea ; 
Endometritis ; 
Pelvic abscess. 

From the first the differentiation is always difficult and frequently 
impossible. The means by which it may sometimes be accomplished 
will be mentioned in the article relating to Specific Vaginitis. From 
the two remaining affections it is readily distinguishable by the spec- 
ulum and vaginal touch. An error will be committed only when the 
practitioner is not mindful of the possibility of its occurrence, and 
draws his conclusions from insufficient data. We have seen two cases 
of profuse and obstinate vaginal discharge regarded as the result 
of vaginitis which were in reality produced by pelvic abscesses that 
emptied their contents into the upper part of the canal. An element 
in such cases calculated to mislead a superficial examiner is the fact 
that vaginitis does really exist to a limited extent as a result of the 
purulent flow from the abscess. This remark likewise holds true in 
reference to endometritis and catarrhal erosion of the cervix. 

Complications. — Vaginitis sometimes produces violent urethritis. 
and less frequently, spreading upward, contrary to the rule, results in 
endometritis, salpingitis, and pelvic peritonitis. 



220 VAGINITIS. 

Specific Vaginitis, or Gonorrhoea. 

Definition. — This variety of the affection consists in inflammation 
of the vulva, vagina, and urethra, arising from a specific contagion 
which is transmitted by a yellow purulent discharge. 

Pathology. — The purulent material which is the contagious element, 
after remaining for some time in contact with the vaginal walls, excites 
in their investing mucous membrane an active hyperemia which results 
in heat, swelling, pain, and an ichorous and abundant purulent secre- 
tion. This inflammation' may be simulated by simple acute vaginitis, 
but its most characteristic features are usually excited by the conta- 
gious influence just alluded to. The disease may affect all the local- 
ities above mentioned at the same time, but very often it is limited to 
the upper part of the vagina, to the vulva, or to the urethra. In some 
cases it is for a length of time concealed in the vaginal cul-de-sac, no 
other part of the vagina being affected. This fact explains how 
women apparently healthy transmit gonorrhoea. 

Causes. — As there is but one cause for scarlet fever, for measles, 
and for variola — namely, absorption of a specific poison or contagious 
material — so is there, it appears to us, but one cause for gonorrhoea. 
It is true that simple acute vaginitis may simulate gonorrhoea so closely 
that the most experienced observer will be foiled in diagnosis, but this 
fact does not prove the diseases to be identical. The poison of gonor- 
rhoea produces inflammatory results as a certain consequence of con- 
tact ; the causes of acute vaginitis produce them as an accident which 
probably in a different state of the patient's system would not have 
occurred. 

Symptoms. — The symptoms of this variety of vaginitis differ very 
little, indeed in many cases not at all, from those of the simple acute 
form. If anything, the difference consists merely in an increased 
severity of the symptoms mentioned for the simple variety. 

Physical Signs. — The vulva, vagina, and urethra will be found 
swollen, tense, red, and hot. In the beginning they are unnaturally 
dry, but very soon a profuse secretion bathes them with a creamy pus, 
sometimes streaked with blood. Should the affection have exerted its 
influence chiefly upon the vulva, pruritus, excoriation, and intense heat 
will be observed. Should the urethra be chiefly or solely diseased, 

instances of which are recorded by 
Fig. 105. Ricord and Cullerier, the most vio- 

lent scalding upon the passage of 
urine will especially annoy the pa- 
tient. 

Differentiation. — It will be seen, 
from what has been already stated, 
that the differentiation of this dis- 

The Gonococcus of Neisser. eage from gi le acute va „j n i tis must 

a, within pus-corpuscle ; , ■, T«» i, f 

b, outside pus-corpuscie (free). be extremely dimcult. In many 

cases it is impossible, for there are 
no signs which can be regarded as positively conclusive. The Tricho- 
monas vaginalis, once supposed by Donne to be pathognomonic of spe- 




■i 



SPECIFIC VAGINITIS, OR GONORRHCEA. 221 

cific vaginitis, is now known to exist in the pus of that which is simple ; 
and urethritis, formerly viewed as diagnostic by many, is sometimes a 
complication of the simple form and is sometimes absent in the specific. 

Recently, a supposed infallible diagnostic sign of gonorrhoea! infec- 
tion has been discovered by Neisser, who under the microscope detected 
a peculiar bacterium which he called the gonococcus, and which he 
claims exists only in this disease. There may fairly be said to be still 
some doubt on this subject. A positive differentiation between a 
severe case of acute or subacute simple vaginitis, and one caused by 
gonorrhoeal infection can, in our opinion, seldom if ever be made. 

The following are the symptoms which should lead us strongly to 
suspect the specific nature of a case : 

Great virulence and acuity in development ; 

Development in a woman previously free from vaginal discharges ; 

Marked urethral complications ; 

Copious purulent discharge ; 

Transmission to the male from coition. 

Although it is true that in many cases these symptoms will render 
us certain in our conclusions, in many others they will exist in cases 
certainly of non-specific character. 

The moral character of a patient, the presence of the undisturbed 
hymen, and the existence of a severe endometritis, with cervical erosion, 
would to some extent incline us to favor a diagnosis of simple rather 
than specific vaginitis. 

Course, Duration, and Termination. — The duration of the disease 
will depend in a great degree upon the character of the treatment 
adopted. Under a proper management even a severe case may often 
be cured in from two to three weeks, but if neglected it may continue 
for months and perhaps years. The morbid action passing up into the 
uterus may exist as an endometritis long after the vaginal trouble has 
disappeared, or it may pass into the bladder and excite cystitis, or down 
their narrow ducts into the vulvo-vaginal glands. 

Dr. Noeggerath in 1873 published a remarkable paper on "Latent 
Gonorrhoea in the Female Sex," 1 in which he declares that certain mor- 
bid phenomena in the female organs which have hitherto been consid- 
ered as separate, and treated independently, possess a common basis 
from which they collectively and separately take their origin, this being 
nothing more nor less than gonorrhoea. "I have," he says, "under- 
taken to show that the wife of every husband who at any time of his 
life before marriage has contracted a gonorrhoea with very few exceptions 
is affected with latent gonorrhoea, which sooner or later brings its exist- 
ence into view through some one of the forms of disease about to be 
described. .... I believe I do not go too far when I assert that of 
every one hundred wives who marry husbands who have previously hail 
gonorrhoea, scarcely ten remain healthy ; the rest suffer from it or some 
other of the diseases which it is the task of this paper to describe. And 
of the ten that are spared we can positively affirm that in some of 
them, through some accidental cause, the hidden mischief will sooner 
or later develop itself." 

1 Die Latente Gonorrkce im Weiblichen Geschlecht. T>onn. 



222 VAGINITIS. 

The diseases to which this author refers as remote consequences of 
latent gonorrhoea are perimetric inflammations, both acute and chronic, 
oophoritis, and catarrh of the genital tract. These when once excited 
are, he declares, incurable, and render the life of the female one of 
misery and danger. These women rarely become pregnant, or if they 
do, either miscarry or bear only one child. To sustain this assertion 
he gives the statistics of 81 cases, of which 31 only became pregnant. 
Of the 31, only 23 went to full term, 3 were prematurely delivered, 
and 5 aborted. Of the 23 who went to full term, 12 had one child 
each during married life, 7 had two children each, 3 had three, 1 had 
four ; and among the 23 women there were 5 abortions. He asserts 
that, although apparently cured, gonorrhoea may exist both in male and 
female an entire lifetime in the latent form, which may at any moment 
burst forth into acute gonorrhoeal inflammation or excite serious uterine 
or peri-uterine inflammation. 

Since the appearance of these views we have considered this subject 
very carefully. While we admit that even years after a gonorrhoea has 
been considered cured some lurking infectious element, dammed up per- 
haps behind a stricture, may transmit the disease, we have failed to get 
evidence of the truth of Dr. Noeggerath's assumptions as to the univer- 
sality of such transmission of disease. Were they true, indeed, it 
appears to us that a healthy woman would be a rare exception to a 
very general rule. 

Complications. — The complications of gonorrhoea in the female are 
numerous and important. The disorder sometimes becomes an exceed- 
ingly grave one, and in some instances destroys life. It may induce 
the following results : 

Cystitis ; 

Inflammation of vulvo-vaginal glands ; 

Endometritis ; 

Fallopian salpingitis ; 

Pelvic peritonitis. 
Mr. Salmon, 1 who first drew attention to inflammation of the vulvo- 
vaginal glands as a result of the disease which we are considering, 
declares that it is quite common. 

The passage of the disordered action into the uterus through the 
tubes, and into the peritoneum, is the most dangerous of all its conse- 
quences, and produces great risk to life from the pelvic peritonitis 
which it excites. 

Granular or Papillary Vaginitis. 

Definition and Synonyms. — This variety of vaginitis was first 
described by Ricord under the name of psorolytrie. In 1844, 
Deville, 2 a pupil of Ricord, described it fully, and it was subsequently 
treated of by Blatin, Guerin, and others under the names of papular, 
glandular, and granular vaginitis. 

Pathology. — By these writers it was regarded as an hypertrophy of 
the muciparous follicies lying imbedded between the rugae of the vagina. 
This hypertrophy, it was thought, was generally the result of preg- 

1 Bumstead on Venereal Dis., p. 172. 2 Archiv. de Med., 4th Series, t. v. 



GRANULAR OR PAPILLARY VAGINITIS. 



223 



nancy, though it Avas admitted that it might arise from simple or spe- 
cific vaginitis. Many recent writers deny the existence of this variety 
of vaginitis, and view it only as a hypertrophy of vaginal papillae, 
the result of the forms of the affection already mentioned. Thus Dr. 



Fig. 106. 




Granular Vaginitis (Heitzmann). 

Bumstead, 1 in speaking of granulations found in the vagina as a result of 
vaginitis, says : " They have been erroneously regarded by Dr. Deville 
as peculiar to the vaginitis of pregnant women." Scanzoni 2 and West 3 
both deny its existence, and upon the same ground — viz. the fact that 
Mancll and Kolliker have discovered very few mucous follicles in the 
vaginal mucous membrane, which are scarcely sufficient, in spite of the 
corroborative discoveries of Huschke, Richet, Becquerel, Guerin, and 
Von Preuschen, to explain the granular feel and appearance of the 
tvhole mucous lining of the vagina in this disease. As a result of 
more extended experience we regard this peculiar condition merely as 
an inflammatory or congestive hypertrophy of the papillae of the vaginal 
mucosa. The physiological hyperemia present during pregnancy readily 
explains the engorgement of the vaginal papillae in many cases. We 
have seen the granular condition extend even to the vulvar mucous 
membrane. It is exceedingly common, and indicates nothing bur an 



Op. tit. 



- Diseases of Females } Am. ed., p. 529. 
3 Diseases of Women, Eng. ed., p. 640. 



224 VAGINITIS. 

aggravated or protracted vaginitis, whether simple or specific, and is by- 
no means confined to pregnancy. 

The disease is characterized by hemispherical granulations, about as 
large as half a millet-seed, scattered thickly over the mucous membrane 
of the vagina and over the cervix uteri. We once saw a case of granu- 
lar vaginitis so striking in its features that the attending physician had 
expressed to the patient's family his fears that malignant disease was 
developing. He became at once convinced of his grave error when 
shown a description of the disease which realty existed, and with which 
he had never before met. 

Causes. — The papillary hypertrophy which gives to the disease its 
characteristic features and name may result directly from pregnancy, 
though it is frequently produced by either simple or specific vaginitis. 
Some women suffer from it in successive pregnancies. 

Symptoms. — It demonstrates its presence by the symptoms already 
recorded as characteristic of simple and specific vaginitis. With these 
pruritus vulvae and a lichenous eruption about the pubes are apt to 
appear. As parturition comes on and puts an end to pregnancy, it 
usually disappears, very often without any treatment whatever. 

Treatment of Vaginitis. — The treatment of the various forms of 
this disease is so similar that it may be described under one head, modi- 
fications being suggested for those cases which have assumed a subacute 
or chronic aspect. If the case be one of acute character, the patient 
should be kept perfectly quiet in bed and locomotion and sexual inter- 
course strictly interdicted. Pain should be relieved by opiate or other 
anodyne suppositories placed in the rectum, and febrile action prevented 
or combated by mild, unstimulating diet and refrigerants. Every fifth 
or sixth hour the patient, placing under the buttocks a bed-pan, upon 
which she lies, and between the thighs a vessel of warm water, should 
by means of a syringe throw a steady stream against the cervix uteri 
for fifteen or twenty minutes, or even for a longer time. The methods 
most appropriate for syringing the vagina are fully described in Chap- 
ter IV. The bowels should be kept in a lax condition by saline 
cathartics, and the ardor urinae relieved by the use of alkaline diuretics. 
Should inflammatory action run very high and much pain be expe- 
rienced, great benefit will be derived from the free administration of 
opium, which should be given until complete quiescence of the nervous 
system is accomplished. 

When the severity of the symptoms has been relieved by this com- 
bination of general and local means, a small tubular or Sims's small 
speculum should be passed, the cervix and vaginal walls cleansed with 
absorbent cotton, the whole canal washed over with a solution of nitrate 
of silver, 9j to Bj of water, and a tampon of carbolized cotton covered 
with vaseline or cold cream applied, so as to prevent all contact of the 
opposing walls. This should be renewed once in every twenty-four 
hours until the parts have become pale and the soreness has disappeared. 
Then dry powders should be substituted for the caustic and vaseline, 
and daily or every other day the vagina should be dusted with a powder 
of iodoform and tannin, equal parts, retained in place by a dry tampon, 
until all hypersecretion has disappeared and the disease is cured. 



ATRESIA OF THE GENITAL TRACT. 225 

During the acute and subacute stages, in the intervals when there 
is no tampon in the vagina, that canal should be freely irrigated with 
a tepid solution of the lead-and-opium wash, about 4 to 6 tablespoon- 
fuls to one pint of water, and if the vulva is much eroded compresses 
soaked in this solution should be kept constantly applied. A case of 
chronic vaginitis usually requires from two to four weeks steady treat- 
ment to achieve a cure. 



CHAPTER XV. 

ATKESIA OF THE GENITAL TRACT, AND RETENTION WITHIN IT OF 
MENSTRUAL BLOOD AND OTHER FLUIDS. 

Definition and Synonyms. — The term "atresia," derived from a, 
privative, and Tpaco, "I perforate," signifies an imperforate condition, 
and should in its strict import be limited to complete closure of an aper- 
ture or canal. Any obliteration or occlusion which is so extreme as to 
remove the case from the class of strictures, and yet is not complete, 
should be styled "stenosis." The genital canal of the female may be 
imperforate at the vulva, in the vagina, or in the canal of the uterus 
itself. 

Any one of these atresiae may act as a barrier to the escape of 
menstrual blood, and create a dangerous retention of that fluid, with 
coincident over-distension ot the vagina, uterus, and Fallopian tubes, 
which may become so excessive as to end in rupture, peritonitis, and 
death. As this is the chief relation in which they are to be con- 
sidered, it seems best to study the varieties of atresia under one 
head. 

Congenital atresia never attracts notice until puberty has arrived, 
and then an examination is instituted on account of non-appearance 
of the menstrual flow, the presence of an abdominal tumor caused by 
uterine or vaginal distension, or the suspicion of pregnancy, some of 
the prominent signs of which are present under these circumstances. 
Acquired atresia is suspected for the same reasons. 

In general terms it may be stated that the higher up the atresia, 
the greater the danger arising from its existence. Thus, an atresia of 
the hymen is the least dangerous of all ; one as high as the os inter- 
num uteri the most so. The reason for this is evident : the former has 
above it, for accommodation of retained fluid, the distensible vagina 
and cervical canal ; the latter has only the uterus itself. Then, too, 
distension of the vagina produces less marked influence upon the Fallo- 
pian tubes than that of the uterus. Distension of the latter does nor. 
it is now thought, cause a reflux through the tubes, but creates a 
species of vicarious menstruation from their Avails. This gives rise to 
hematosalpinx, which so often ends in rupture of the tube that that 
accident should be feared as one of the most decided dangers connected 
with the condition. 



226 ATRESIA OF THE GENITAL TRACT. 

This tubal rupture may occur in two ways : first, sudden emptying 
of the uterine contents creates uterine contraction, which at once 
extends to the muscular fibres of the tubes, and rupture is the result ; 
or, previous peritonitis having fixed the tubes, descent of the uterus 
drags upon them so powerfully as to cause their rupture or laceration 
of the false membranes which hold them. 

It must not be forgotten, however, that, although it is an exception 
to the rule, vaginal atresia may cause distension of the uterus and 
tubes by gradually dilating the uterine tract, and before every opera- 
tion this effect should be considered. 

Atresia of the hymen or imperforate hymen has already been con- 
sidered in the preceding chapter, to which the reader is referred. 

Stenosis and Atresia of the Vagina. 

Like the uterus, the vagina is in foetal life created from the approx- 
imation and amalgamation of the Miillerian ducts upon the median 
line. In the former a great variety of congenital malformations are 
the result of arrest of development of these parts. So is it also with 
the latter, the chief of its anomalies being double, unilateral, diminu- 
tive, and rudimentary vagina, or no vestige of it may exist. The con- 
dition which is now to engage our attention may be due to such con- 
genital arrest of development or to accidental causes developing after 
adult life has been reached. This condition was well known to the 
ancients, but it is only during modern times that its cure has become 
possible, in consequence of the operation performed by Amussat, Sims, 
Emmet, and others. 

Varieties. — There may be no trace of the canal, the ducts of 
Muller seeming to have failed entirely to develop ; there may be a dis- 
tinct fibrous cord marking the site which it should have occupied, some 
slight development appearing to have occurred ; development may 
exist for some distance up the canal, failure having taken place above; 
or one Miillerian duct has developed in part above and another below, 
giving two cul-de-sacs, separated from each other by impervious tissue. 
The whole canal is not rarely well developed, while the hymen guards 
its outlet as an unyielding and completely-closed obturator membrane. 
The last of these vaginal atresia, and. fortunately, the most frequently 
met with, is depicted in Figs. 103 and 104. 

Not only is the operation for relief in such a case much more simple 
than in other varieties of atresia, the uterus is usually not involved in 
the dilatation and the danger of trouble after operation is not so great. 

Pathology. — Congenital defective development of the vagina is one 
of the frequent causes of this condition ; besides, as a result of injury 
from mechanical, chemical, or pathological agencies, a vagina once fully 
developed may close from adhesion of its walls ; its calibre may be 
diminished by absolute removal of its component structures in conse- 
quence of ulceration or sloughing ; or the other parts of the female 
genital system may go on to full development, while this is arrested in 
its growth and remains a fibrous cord instead of a distensible canal. As 
a congenital malformation there may be a double vagina, with or with- 



STENOSIS AND ATRESIA OF THE VAGINA. 227 

out a double uterus. One of these vaginae or uteri may be patulous, 
the other closed. In this case there will be a menstrual discharge from 
the open side, and retention in the other half — that is, hsematokolpos, 
or hnematometra unilateralis — according as the hymen or the external 
os is imperforate. The diagnosis of this condition is often difficult. 
Occasionally suppuration of the effused blood takes place, and we then 
have pyokolpos or pyometra, respectively. 

Causes. — The following special causes may be enumerated as pro- 
ductive of it : 

Impervious hymen ; 

Arrest of development of vagina ; 

Prolonged and difficult labor ; 

Chemical agents locally applied ; 

Mechanical agencies exciting inflammation ; 

Sloughing, the result of impaired vitality ; 

Syphilitic or other extensive ulcerations. 
One of the cases which have come under our observation resulted 
from syphilis ; several from prolonged labor ; one from the accidental 
passage of a sharp bit of wood up the vagina ; another from retention 
of the foetal body for two hours after delivery of the head ; and one 
from a tampon of cotton saturated with persulphate of iron. Among 
the causes of sloughing from impaired vital force should be especially 
mentioned the continued and eruptive fevers, typhus fever, scarlatina, 
variola, etc. ; and cholera as a cause of the accident is referred to by 
Courty. 

Symptoms. — The disorder will demonstrate its existence only by 
incapacitating the vaginal canal for its important functions, copulation 
and transmission of menstrual blood. Should it occur in one too young 
or too old to require such functions from the vagina, no suspicion will 
be aroused as to its existence. The notice of the practitioner will 
generally be called to the patient by amenorrhcea or by an inability 
to perform the act of coition. Should the menstrual hemorrhage have 
taken place, a large amount of blood will generally be found confined 
above the constricted part of the canal, and violent contractions will 
have demonstrated the efforts which the parts have made to expel the 
accumulation. Besides these, no other rational signs will show them- 
selves, but they will be sufficient to urge upon the attendant the neces- 
sity for a physical exploration. (For a full description we refer the 
reader to the preceding chapter.) 

Physical Signs. — The patient being placed upon the back and vagi- 
nal touch attempted, entrance of the finger into and up the vagina will 
be found to be impossible. Investigation will prove that this is not due 
to vaginismus or adhesion of the labia majora, and rectal touch will, in 
cases involving the vagina, usually discover that canal running up the 
pelvic cavity as a fibrous cord, though sometimes no trace of it will be 
found. 

Results. — From the mere occlusion of the vagina there is no imme- 
diate or direct derangement. But in cases where menstrual blood is 
poured out by the vessels of the uterine mucous membrane, and is accu- 
mulated at each monthly epoch in the portion of the canal above the 



228 ATRESIA OF THE GENITAL TRACT. 

stricture or in the uterus, which is dilated by its retention, rupture of 
these organs or of the Fallopian tubes may occur ; discharge from these 
tubes into the peritoneum may take place, and pelvic hematocele be the 
consequence ; or the retention of the menstrual flow may produce all 
those nervous and cerebral symptoms so characteristic of such an 
occurrence. 

Prognosis. — The prognosis of these cases, as regards the possibility 
of removal of the abnormal state, will depend upon the extent and 
completeness of the obliteration and destruction of tissue. The smaller 
the amount of vaginal tissue found by rectal touch and examination by 
a sound in the bladder to exist, and the more complete and extensive 
the adhesion of the vaginal walls, the more closely will the case resem- 
ble one of entire absence of the vagina. The prognosis as to permanent 
cure will greatly depend upon the patient. If she be a woman of good 
sense and perseverance, and keep up after operation distension by the 
vaginal plug, not for months, but for years, the result is often a very 
good and permanent one. If, on the other hand, she ignores the risk 
attendant upon the cessation of its use, contraction will probably recur. 
During the process of making a canal between the bladder and rectum 
one of these viscera is very apt to be cut into, or the peritoneum may 
be opened at the fornix vagin?e. If a depot of menstrual blood be 
reached and evacuated, death is by no means rare from septicaemia, 
purulent absorption, or a septic endometritis which ends in lymphan- 
gitis or in salpingitis and peritonitis. 

The prognosis is greatly governed, too, by the variety of atresia 
with which we deal. Occlusion due to impervious hymen warrants <a 
very favorable prognosis ; that arising from accidental causes likewise ; 
that from congenital cause in which the uterus and vagina can be dis- 
tinctly discovered as existing, a less favorable one ; while that due to 
absence of vagina and uterus, as far as clinical observation can verify 
the fact, a wellnigh hopeless one. In other words, the more complete 
the absence of vaginal tissue and that of other organs of the pelvis, 
the more unfavorable will be the prognosis as to recovery from surgical 
interference. 

Should deformity of the external genitals exist, the uterus not be 
discoverable, and no signs of distress at menstrual epochs show them- 
selves, it may be concluded that the case is one of absence of the 
vagina, and not of complete atresia. But, thanks to the boldness of 
Amussat, even absence of the vagina does not preclude the possibility 
of establishing an artificial canal. The importance of the differentiation 
consists in the fact that the surgeon should in such a case be doubly 
cautious and circumspect in his efforts and guarded in his prognosis. 
It may at first thought appear that in case there be no evidence of 
the existence of uterus or ovaries, and no inconvenience be experienced 
from retention of menstrual blood, it would not become necessary to 
resort to an operation to render the vagina pervious. But so great is 
the unhappiness often resulting from incapacity of the woman for the 
sexual act that this becomes a reason for her to demand the resources of 
art, and a valid ground for interference on the part of the surgeon. If 
no such demand is made for surgical interference, it would, in such a 



STENOSIS AND ATRESIA OE THE UTERUS. 229 

case as that just depicted, be an unwarrantable procedure. Not only 
is the patient exposed to danger without sufficient indication ; she is 
thus exposed for the opening of a canal which has a marked tendency 
to close completely. 

The rule with reference to operation for atresia due to congenital 
closure or absence of the vaginal canal itself should, it seems to us, be 
this : it should be resorted to (a) if menstrual blood be imprisoned ; (b) 
if a uterus can be distinctly discovered and the patient be suffering 
from absence of menstruation ; (c) if the necessity for sexual intercourse 
be imperative : it should be avoided unless demanded by one of these 
considerations. 



Stenosis and Atresia of the Uterus. 

Definition and Frequency. — This consists in closure of the canal of 
the cervix so that no fluid can escape. In its partial form, that of 
stenosis, it is by no means rare, but fortunately complete atresia is 
decidedly so. 

Varieties. — Uterine atresia may be either congenital or acquired. 
When it is congenital it may exist at the os internum, at the os exter- 
num, or involve the whole cervical canal. Sometimes the cervix is 
exceedingly small, while the body is greatly distended by fluids. 

When the condition is acquired, it may also be limited to one or 
both ora or involve the whole extent of the canal. The causes w r hich 
most commonly induce it are the following : 

The use of caustics ; 

Senile atrophy ; 

Sloughing after parturition ; 

Amputation of the uterine neck. 
The first of these (chiefly solid nitrate of silver and nitric acid) is a 
very common cause of severe stenosis, and sometimes produces even 
complete atresia. At the present day the universal and reckless use of 
these caustics is fortunately far less common than formerly, and hence 
such results are not so frequently met with. The second is so very com- 
mon in old age that Hennig declares that out of 100 women who had 
passed fifty years of age, about 28, over a quarter, suffered from it. 
The third and fourth are often met with as causes. 

Results. — It might at first thought be supposed that uterine atresia 
occurring after the menopause would be, as it usually is before puberty, 
a matter of no moment. As a rule this is so, but there are exceptions 
to both rules. In the old woman a watery secretion sometimes takes 
place, giving rise to hydrometra ; suppurative action may occur, creating 
pyometra ; and decomposition of the imprisoned fluid gives rise very 
rarely to a development of air, physometra. Very rarely hydrometra 
is found before puberty, and hamiatometra in old women. 
The evils which result from uterine atresia are — 

Hnematometra ; 

Hematosalpinx ; 

Hydrometra. 



230 



ATRESIA OF THE GENITAL TRACT. 



And the consequences of these, if they be left uninterfered with, may- 
be — 

Peritonitis ; 

Pelvic hematocele ; 

Rupture of the vagina, uterus, or tubes ; 

Septicaemia. 

Prognosis. — In a patient suffering from uterine atresia with retention 
of menstrual blood the prognosis is usually favorable ; that is to say, 
if proper surgical interference is not too long delayed. With our 
present method of asepsis, septic infection need scarcely be feared. If 
the evacuation of the retained blood be delayed too long, rupture of 
the distended uterus or Fallopian tubes and fatal peritonitis may ensue. 

In mere partial closure or stenosis of the uterine canal of course all the 
symptoms of retention are much less aggravated, and become apparent 
only when the escape of the retained fluid is less rapid than its secretion. 

Diagnosis and Differentiation. — It is sometimes exceedingly diffi- 
cult to differentiate the tumor formed by retained menstrual blood in 
the uterine tract from fibrous tumors, malignant growths, ovarian cysts, 
hematocele, and pregnancy. The rational signs which enable us to do so 
are these: In all but the last menstruation is commonly increased, 
while here it is suppressed ; the tumor is surely uterine, and not ovarian, 
retro- uterine, or ante-uterine ; it has come on slowly, and not suddenly , 
as the tumor of hematocele does ; and at every monthly epoch an 
increase of inconvenience is noticeable from its presence. Physical 



Fig. 107. 



Fig. 108. 





Uterine Atresia at Os Externum. 



(Diagrammatic.) 



Uterine Atresia at Os Internum. 



signs yield more important results still. If an attempt be made cau- 
tiously to pass the uterine sound or probe, the cervical canal will be 
found to be closed. This constitutes the crucial test. 



STENOSIS AND ATRESIA OF THE UTERUS. 231 

The diagrams, Figs. 108 and 109, show the varieties of hsematometra 
occurring in cervical atresia. 

Fig. 109 presents an instance of atresia in one of the uteri in a case 
of double uterus, the other being free to perform all its functions. 

In the last case menstruation would be regular, the uterus be sus- 
ceptible of recognition by conjoined manipulation and the passage of 

Fig. 109. 




Atresia in one-half of a Double Uterus (diagrammatic). 

the sound to the fundus, while one-half of the abnormally developed 
organ would present the large tumor seen in the diagram. Diagnosis 
would be possible here only by very careful conjoined manipulation. 

Treatment. — To surgery alone can we look for any hope of recovery 
or of safety in cases of atresia of the female genital canal. I shall treat 
of this part of the subject as it applies to all varieties of atresia — ute- 
rine, vaginal, and their subdivisions. It is evident that to do justice 
to it operative interference must be described as applying to the follow- 
ing cases : 

1st. Where there is atresia of the hymen alone. 

2d. Where the vaginal canal is closed only for a small portion of its 
course. 

3d. Where there is complete closure or entire absence of the vagina. 

4th. Where there is atresia of the uterine neck. 

Where there is Atresia of the Hymen alone. — See preceding- 
chapter. 

Where the Vagina is Closed only for a Small Portion of its Course. 
— This deformity may be either congenital or acquired, the causes in 
the latter case being contractions following injuries during parturition, 
acute vaginitis, or senile contraction. The treatment is entirely sur- 
gical, and is practically the same as described in the next section. 

Where there is Entire Closure or Absence of the Vagina. — In the 
first case a hard, fibrous cord will mark the position of the vagina : in 
the second no indication of it will be found, and a canal must be cleared 
between rectum and bladder out of a space occupied by areolar tissue. 



232 ATRESIA OF THE GENITAL TRACT. 

Should accumulation of menstrual blood have occurred, the operation 
will prove much easier than if it has not, for its greatest difficulty con- 
sists in finding the cervix uteri, and in cases of accumulation this is an 
easy matter. 

The other operations for atresia become insignificant when compared 
with this one, which requires an unusual amount of skill and caution. 

Before operation, if there be any doubt as to the presence of the 
uterus or as to its size or position, the hand, except the thumb, may 
be introduced into the rectum after stretching llie sphincter, and a full 
and satisfactory exploration made. 

If on account of great obesity it be found impossible to appreciate 
by conjoined manipulation the extent of tissue existing between the 
bladder and rectum, and consequently the course in tyhich the vagina 
is to be opened or perhaps absolutely constructed, the, urethra may be 
rapidly distended by sounds so as to admit the finger to the bladder. 
Then the index and middle fingers of the right hand being carried up 
the rectum, and the index of the left introduced into the bladder, this 
important point may be ascertained. 

Before operating, the patient should be anaesthetized and the blad- 
der and rectum emptied of their contents. She should be placed in 
the lithotomy position upon a table before a good light, and the ope- 
rator should have four assistants at his disposal. 

Formerly the operation was performed by two methods — that of 
Dupuytren (1818), which consists of breaking a passage by the finger, 
cutting obstructions which cannot thus be overcome, and syringing 
out the cavity afterward, the whole operation being finished at one 
sitting ; and that of Amussat (1832), which consists of working with 
the finger and dull instruments, overcoming resistance by pressure 
rather than by incision, and completing the operation not in one, but 
in several sittings. 

At present we perform the operation for incomplete or complete 
atresia of the vaginal canal in the following manner, finishing it with 
ease in one sitting: The patient, being thoroughly anaesthetized, is 
placed in the lithotomy position, and the surgeon makes with a bis- 
toury or sharp-pointed scissors a transverse incision into the presenting 
portion of the recto-vaginal septum, with a sound in the bladder and the 
index finger of his left hand in the rectum as a guard against wound- 
ing either of these viscera. The index of the right hand, aided by 
the scalpel handle or the closed points of the blunt scissors, gradually 
forces its way through the obstruction and separates the rectal from 
the vesical wall, in this way forming a new vaginal canal. If the con- 
striction is but a partial one, the finger will soon reach the pervious 
portion of the vagina, and at its upper end will encounter the normal 
cervix uteri. If, however, the atresia is total — whether congenital 
or acquired matters not — the region of the vaginal cul-de-sac may be 
reached without the finger of the operator being able to distinguish 
the cervix ; only a careful examination, aided perhaps by a specular 
inspection, may in such cases enable the operator to discover the cervix 
and the external orifice of the uterine canal. The danger of wound- 
ing either the bladder or the rectum is very great during this opera- 



STENOSIS AND ATRESIA OF THE UTEAUS. 233 

tion, and therefore the use of cutting instruments should be avoided as 
much as possible. A vaginal canal as nearly like in proportion to that of 
the adult woman having been formed, precautions must be taken against 
its contracting and closing again, which occurrence is more than likely 
to take place even if the most stringent care is observed. In order to 
avoid the closure of the external os, we have found it necessary several 
times to unite the wall of the vaginal cul-de-sac to the mucous mem- 
brane of the cervical canal by interrupted catgut sutures, and to 
keep a hard-rubber plug in the uterine canal for some weeks. In any 
case of vaginal atresia operated upon by this method it is absolutely 
imperative to prevent its recontraction by introducing into the vagina 
a closed tube of hard rubber or glass, a so-called vaginal plug, of a 
dimension corresponding to the size of the normal adult, vagina, which, 
must be worn for a number of months more or less permanently — after 
a while at least several hours each day — until the danger of contrac- 
tion has disappeared. We have already referred to this treatment in 
the chapter on Vaginismus. 

There is usually some oozing during and following this operation, 
which is easily arrested by either the plug or by packing the new- 
formed passage temporarily with iodoform gauze, on the removal of 
which, five or six days after the operation, the vaginal plug may be 
inserted. If carefully performed the operation is unattended by dan- 
ger. This operation can usually be performed in one-half to one hour, 
and is not especially difficult in the hands of a surgeon of ordinary 
skill and caution. 

One note of warning should be heeded ; and that is, that unless 
the new-formed canal is kept patulous by the daily use of the vaginal 
plug above mentioned for at least a year, it will inevitably reclose. 
This statement may be somewhat modified in cases where the woman 
is married and enjoying marital relations. 

Where there is Atresia of the Uterine Neck. — The operator should 
decide by careful conjoined manipulation as to the degree of uterine 
distension which exists above the cervical closure. 

Having decided that it is wise or necessary to empty the uterus of 
the retained secretions, the operation may be performed under careful 
antiseptic and antiphlogistic precautions without unnecessary delay. 
The patient is anaesthetized, placed in the Sims position, the speculum 
is introduced, the vagina is thoroughly irrigated with a 1 : 10,000 
bichloride solution, and an aspirator needle is then introduced through 
the spot corresponding to the obliterated external os, in the direction 
of the uterine cavity as previously ascertained by bimanual palpation. 
When the withdrawal of the piston shows by the flow of thick dark blood 
that the uterine cavity has been properly entered, a fine, sharp-pointed, 
straight bistoury is passed alongside of the aspirator needle, and by means 
of several superficial incisions the cervical canal is opened sufficiently to 
allow of the free escape of the retained blood. A steel two-branched dila- 
tor (one of the Ellinger pattern) is then introduced through the open 
canal and gently separated, so as to thoroughly stretch the passage. 
When the blood has escaped, the uterine cavity is gently washed out 
with a 1 : 10,000 bichloride solution, and a strip o\' iodoform gauze is 



234 ATRESIA OF THE GENITAL TRACT. 

passed up into the cavity to afford a ready means of aseptic drainage. 
The vulva is covered by a pad of bichloride gauze and an ice-bag applied 
over the abdomen. The patient is put to bed, and kept there for sev- 
eral days until all danger of inflammatory reaction has disappeared. 
The iodoform gauze is removed after two or three days, the vaginal 
cavity is again irrigated, this time with a 2 per cent, carbolized solu- 
tion, and the gauze is replaced in order to ensure the patulousness of 
the canal. As soon as the uterus has contracted thoroughly and the 
discharge has ceased, a perforated hard-rubber or metal plug may be 
inserted into its canal in order to allow such secretions as may form to 
escape and prevent a return of the former contraction. The regurgi- 
tation of the retained blood into the Fallopian tubes in consequence 
of a rapid evacuation of the uterus need not be feared, as it formerly 
was. 

If menstrual blood has been imprisoned above the strictured por- 
tion of the vagina, the canal should, for a fornight after operation, be 
kept scrupulously clean by injections of tepid water practised twice a 
day. If the uterus and tubes have been distended by retained fluid, 
the cavity of the former should, just after the operation, be carefully 
washed out with tepid water very slightly impregnated with carbolic 
acid, tincture of iodine, or Labarraque's solution of soda, as advised by 
Courty. The patient should then be kept as quiet as possible in the 
recumbent posture and slightly under the influence of opium. 

The period at which operation should be resorted to for congenital 
atresia is a subject of importance. Velpeau advocated operating in 
infancy, but all modern surgeons consider the approach of menstruation 
as a more appropriate time. Indeed, the symptoms which first call 
attention to the anomaly are scarcely ever observed until the period of 
puberty has been reached. In adult life, especially in married women, 
the deformity should be remedied as soon as discovered. Should the 
menopause have arrived, no operation will be called for unless hyclro- 
metra exist or marital relations demand it. 

It should not be forgotten that delay in interference is often very 
disastrous during the period of menstrual activity, for lives have in 
numerous instances been destroyed by rupture of the Fallopian tubes, 
and even of the uterus itself, as seen by Peusch. This observer drew his 
conclusions from 258 cases of atresia, in 18 of which rupture of the Fal- 
lopian tubes from distension by menstrual blood occurred. In one in- 
stance of atresia we saw an hematocele the size of an infant's head result 
from discharge of blood from the tubes into the peritoneal cavity. It is 
possible that the mental emotion of the patient and her struggles during 
the operation may account for the escape of blood into the peritoneum, 
as noted by Bernutz. Hence, every effort should be made to avoid 
these by complete anaesthesia, and care should be taken not to allow of 
pressure upon the uterus, either intentional or accidental. 

In cases in which vaginal and uterine atresia have existed together, 
and the uterus only is distended by blood, there can be no good reason 
urged for not completing the removal of both atresia at one sitting. 
It is perfectly practicable to secure complete liberation of the uterine 
neck and perviousness of the vaginal canal at the same sitting, without 



DISEASES OF THE FEMALE URETHRA, ETC. 235 

danger to the patient or a risk of failure in the operation. The exces- 
sive caution which was perfectly proper before the days of antisepsis 
need now no longer be observed if the rules governing the surgical 
practice of the present day are strictly carried out. 

Vaginal Cysts. — Partly as results of embryonal malformation (per- 
sistence of Gartner's ducts or the continuation of the ureters), and partly 
by occlusion of some of the muciparous follicles, occurring chiefly in the 
upper portion of the vagina, we find not very unfrequently cysts of the 
size of an almond to a lemon, with more or less tense walls and limpid 
somewhat viscid contents, in different parts of the vagina. If they 
are remnants of Gartner's ducts, they are situated in the lower part of 
the anterior vaginal wall ; if dilated follicles, they occur in the vaginal 
vault. At times we believe they may be very much distended cervical 
glands which have gradually dissected up the mucous membrane covering 
the cervix and encroached on the vaginal wall. They are of no conse- 
quence, except that those in the anterior vaginal wall may simulate 
cystocele. To cure them it is merely necessary to incise them thor- 
oughly, scrape their cavities with the sharp curette, and pack them with 
iodoform gauze until healed. 



CHAPTER XVI. 

DISEASES OF THE FEMALE UKETHRA, BLADDER, AND URETERS. 

Examination. — The meatus urinarius may be examined by inspec- 
tion. In order to expose the first part of the urethra, the lips of the 
meatus may be separated by the fingers or an ordinary dressing-forceps, 
or a steel two-branched dilator may be passed into the canal and gently 
separated, or a urethral speculum specially devised for the purpose may 
be employed, by means of which the walls of the canal can be exposed 
nearly to the neck of the bladder. Such urethral specula have been 
devised by Stein and others. To examine the interior of the bladder, 
either the finger, a sound, a speculum, or so-called endoscope can be 
employed. In order to introduce the finger into the bladder, the ure- 
thra and vesical neck must first be gently dilated by means of either 
graduated steel or hard-rubber sounds (a set of which was devised by 
the late Prof. Simon of Heidelberg) ; and when once the urethra is so 
dilated that the little finger can be passed into the bladder, it may be 
followed at once by the index finger, care being taken to avoid force 
which might lacerate the walls of the urethra. With the little or the 
index finger in the bladder a very fair palpation of its walls may be 
made, especially if the organ is pushed toward the examining finger by 
means of a finger of the other hand in the vagina or by the other hand 
on the abdomen. To permit an ocular inspection of the interior of the 
bladder we may employ endoscopes devised by Winckel, Skene, and, 
best of all, by Nitze, which latter has perfected a most ingenious appa- 
ratus for exposing the interior of the bladder by means of electric light. 
Of course the area revealed by such an endoscope must be very small. 



236 



DISEASES OF THE FEMALE URETHRA, ETC. 



and the instrument is therefore useful only in detecting either the ori- 
fices of the ureters or certain ulcerated spots on the mucous membrane. 
Pawlik, late of Vienna and now of Prague, and, following in his lead, 
H. A. Kelly of Baltimore, not to mention various others, have practised 



Fig. 110. 



JiBW 




Palpation of Ureters (Winckel). 

TrL, ligameutura trigonale ; BGr, fundus of bladder; hBW, posterior wall of bladder; b, b, openings of 

ureters; a, a, a, upper border of lig. trigonale. 

a catheterization of the female ureters by means of stiff hollow tubes 
introduced through the urethra, which they guided into the ureteral 
orifices with the assistance of the vaginal touch. This manoeuvre, it 
will be readily understood, requires a considerable amount of practice, 
and we dare say is not always successful even in the hands of its origi- 
nator. Its object is chiefty to obtain urine from one ureter and one 
kidney alone as a means of settling the question as to which side is 
diseased in cases of doubtful pyelonephritis, and also in order to decide 
whether the one ureter or the other is obstructed by a suspected 
impacted stone. 

Diseases of the Urethra. 

Caruncles and Prolapsus of the Urethra. — Both of these 
conditions have already been spoken of in a previous chapter, to which 
we refer. 

Hypospadias likewise, being a congenital malformation, has been 
discussed under Hermaphrodism. 

Urethritis. — Urethritis in the female is by no means as common as 
it is in the male. If acute, it is usually produced by gonorrhceal infec- 



DISEASES OF THE URETHRA 



237 



tion. The chronic form may be either the consequence of the acute 
variety just mentioned, or it may be due to some irritation of long 
standing, such as caruncles, urethrocele, and chronic cystitis. 

Treatment. — It is usually easily cured, either by removal of the 
cause or by the application of mild caustics and copious tepid irriga- 
tions. Skene of Brooklyn has discovered two small tubular glands 
running along on either side of the urethra and opening just within 
the meatus, which are liable to become infected by the gonorrhceal 
poison, and to prevent the cure of the urethritis until they are slit 
open and thoroughly cauterized. They are easily detected by inspec- 
tion and the insertion of a fine probe. 

Urethrocele. — This condition is one to which comparatively little 
attention has been paid by the majority of gynecologists, only those 
gentlemen who were specially interested in diseases of the urinary 
organs in the female having studied it and mentioned it in their writings. 
It consists in a sacculation of the posterior wall of the urethra, which 

Fig. 111. 




Urethrocele. 

protrudes at the vaginal orifice and simulates a minor degree of cysto- 
cele or prolapse of the anterior vaginal wall and bladder. 

The differential diagnosis can easily be made by introducing the 
sound into the bladder, and on withdrawing it, it will be found ro sink 
into a pocket in the posterior wall of the urethra about midway between 
the neck of the bladder and the meatus. 



238 DISEASES OF THE FEMALE URETHRA, ETC. 

The cause of this disease is usually a catarrh of the urethra, accom- 
panied by relaxation of its walls and a gradual separation of some of 
the muscular fibres of the lowest part of the posterior wall. Little by 
little the urine pushes aside and downward the weakened tissues of the 
urethra, and a sac forms in which the urine accumulates, becomes offen- 
sive, and in its turn helps to increase the urethritis. 

The symptoms complained of are those of painful, chiefly scalding, 
micturition, which are not relieved except when the patient pushes up 
the prolapsed portion of the urethra. 

The treatment consists in making a small opening at the most depend- 
ent portion of the urethral pouch and sewing the mucous membrane of 
the urethra to the mucous membrane of the vagina by catgut sutures. 
Emmet, who has made a special study of this affection, calls this " but- 
tonholing ' ' the urethra, and excises a certain portion of the usually 
redundant urethral mucous membrane. Free drainage through this 
fistula should be maintained by means of frequent introductions of 
the sound and irrigation through the meatus. 

[I have met with such a case in which the irritating discharge through 
the meatus caused the growth of caruncles which had been removed twice 
before by a very eminent practitioner of this city. Still they returned, 
and when the patient consulted me I repeated the same operation, at the 
same time applying strong nitric acid. Notwithstanding, the caruncles 
returned, and it was not until then that my attention was called to the 
sacculation of the urethra and to the part which it played in the reproduc- 
tion of the caruncles. I then buttonholed the urethrocele, and, finding the 
opening very prone to close, kept it open by a fine rubber drainage-tube 
passed through it and the meatus and tied over the vestibule. As soon as 
the urethral mucous membrane regained its normal character I withdrew 
the drainage-tube, and the fistula closed of itself. The caruncles never 
returned, and the woman made a permanent recovery. — P. F. M.] 

Fissure of the Urethra. — This disease usually occurs at the 
neck of the bladder, and manifests itself by excessively painful mic- 
turition, chiefly spasmodic contractions or tenesmus. 

The diagnosis can be made only by inference or by ocular inspection. 

Irritable Urethra. — Many women complain of a frequent desire 
to pass water, followed by tenesmus, without this symptom being dis- 
tinctly referable to any pathological condition of the canal. It very 
commonly follows catarrh of the bladder, or it may be the result of 
exposure to cold or of some temporary and accidental irritation of the 
bladder, such as too frequent coition, intra-uterine treatment, pressure 
of a pessary, etc. While the disease is of no special importance and 
in no way serious, it nevertheless annoys its possessors very much, and 
they clamor for relief. It can be cured very readily by the employ- 
ment of the same method which we advise for fissure of the urethra — 
namely, by dilating the whole urethral canal, from the meatus through 
the vesical neck, with dressing-forceps or some form of dilator until the 
little finger can be easily passed into the bladder. The application of 
a solution of carbolic acid and glycerin, equal parts, to the whole canal 



DISEASES OF THE BLADDER. 239 

will materially aid in effecting a cure, although the urination will be 
painful for several days until the effects of the treatment have worn 
away. This dilatation may have to be repeated several times until a 
permanent cure is effected. 

Stricture of the Urethra. — We have found this disease very 
rare in the female, although Skene claims to have met with it very 
frequently. Dilatation by graduated sounds or Ellinger's dilator will 
effect a speedy cure. 

Diseases of the Bladder. 

Catarrh of the Bladder ; Cystitis. — Definition. — Catarrh of 
the bladder means an inflammation of the mucous membrane lining 
that viscus ; it may be either acute or chronic. 

Causes of the Acute Form. — Exposure to cold, pressure by the 
presenting part of the child during parturition, gonorrhoeal infection, 
acute inflammation of the pelvic peritoneum or cellular tissue. 

Causes of the Chronic Form. — Continuance of the acute variety, 
pressure by enlarged uterus or pelvic tumors, stone in the badder, 
pyelonephritis. 

Symptoms. — The acute form manifests itself by sudden severe pain 
in the suprapubic region, a chill, and more or less high temperature, 
with painful micturition, and high-colored urine containing an unu- 
sually large proportion of salts. This stage may continue a few days 
or a week, and then gradually subside, the pain and temperature dis- 
appearing, the urine gradually becoming clear and more profuse in 
quantity, and recovery taking place; or it may lapse into the chronic 
condition, which is characterized by frequent desire to urinate, by 
more or less constant and annoying pressure over the region of the 
bladder, by cloudy rather scanty urine, which on standing deposits a 
sediment showing under the microscope cells of bladder epithelium — 
in the later stages pus-cells and shreds of connective tissue from the 
mucous membrane of the bladder. The specific gravity of the urine 
is usually between 1015 and 1020 ; its reaction acid, except when it 
has been retained some time in the bladder and has had an opportu- 
nity to become ammoniacal, when it is strongly alkaline. Patients 
afflicted with chronic catarrh of the bladder not only are obliged to 
pass water more frequently than usual during the daytime, but chiefly 
so at night, and in aggravated cases of the disease the poor sufferer 
may find herself compelled to rise fifteen or twenty times during the 
night, each time voiding only a very small quantity of highly irritant 
and offensive urine, each attempt being followed by severe tenesmus. 
It stands to reason that under such a strain not only the nervous sys- 
tem, but also the general health and nutrition, of the patient soon give 
way ; and we may truly say that there is no disease in all the realm 
of gynecological medicine which can prove more agonizing and more 
debilitating than a severe case of chronic cystitis. 

Duration. — While acute cystitis may be cured by remedies early 
applied, or even cure itself, this is seldom the case with chronic cys- 
titis. Once in a while a case of not very Ions standing may under 



240 DISEASES OF THE FEMALE URETHRA, ETC. 

favorable circumstances gradually improve and recover without any 
very active treatment ; but the longer the duration of the disease, par- 
ticularly the more the structural integrity of the mucous membrane of 
the bladder is affected, the more tedious will be the recovery under any 
form of treatment; and indeed in some cases nothing but an operation 
hereafter to be described will succeed in affording relief. 

Prognosis — The prognosis in early cases is usually good, but the 
longer the disease has lasted the more likely is the inflammation to 
spread up along the ureters, and finally affect one or both kidneys. 
In addition to the catarrh of the bladder and its agonizing if not 
necessarily dangerous symptoms, we will then have the serious compli- 
cation of purulent inflammation of the pelvis of the kidney — so-called 
pyelonephritis — which, if not relieved, and that usually by a counter- 
opening into the kidney through the lumbar region, or even by removal 
of the diseased organ, will sooner or later terminate fatally. 

Treatment. — Acute cystitis should be treated by hot fomentations 
over the lower part of the abdomen, diluent drinks containing the 
citrate or acetate of potash and some demulcent, such as flaxseed tea 
or mucilage of gum arabic, warm baths, opium, and, if the fever 
requires it, one of the antipyretics already referred to. These agents, 
together with absolute rest in bed and profuse diaphoresis, will usually 
soon check the disease or at all events abate the acute stage. In 
chronic cystitis there is usually no elevation of temperature. The 
treatment is directed more toward changing the character of the urine, 
so as to render it less irritating to the interior of the bladder : if it 
is acid, rendering it alkaline by the use of benzoate of sodium ; if 
it is alkaline, diluting it by the administration of citrate or acetate 
of potash in infusions of uva ursi, buchu, or triticum repens ; further, 
in diluting it freely by the copious administration of the waters of 
some of the springs noted for their action upon the kidneys and the 
bladder, among which those of Wildungen in Germany, Vichy in 
France, and the Bethesda, Londonderry, and Buffalo Lithia waters in 
this country should be mentioned. A bland, unirritating diet, with 
the omission of salt, spices, asparagus, and spirituous and malt liquors, 
should be observed. In addition to this, if the urine shows very 
marked evidences of pus or detritus of the vesical mucous membrane, 
which would indicate probable ulceration of the organ, it should be 
freely irrigated once or twice a day by means of a soft rubber double 
catheter (recurrent), a pint to a quart of a tepid 1 : 1000 boracic-acid 
solution being thrown in at each sitting until it emerges perfectly clean, 
or a 2 per cent, carbolic-acid solution, or a weak (one tablespoonful to 
a quart) solution of chloride of sodium may be used instead. If this 
fails to give relief, and still the ulceration of the bladder continues, 
two drachms of a solution of nitrate of silver (1 drachm to 1 ounce) 
may be injected into the bladder with a glass syringe, being followed 
within five minutes by a solution of chloride of sodium of the strength 
above mentioned to neutralize the caustic. 

This treatment may have to be repeated several times. A favorite 
prescription of ours is five grains of the benzoate of sodium to half 
an ounce of the infusion of triticum repens, buchu, or uva ursi, given 



DISEASES OF THE BLADDER. 241 

every three hours. Pain should be relieved by morphine suppositories 
if necessary, but they should be used with great caution in order to 
prevent the growth of the morphine habit ; and warm sitz-baths or full 
baths at a temperature of 100°-105° F. will be found exceedingly 
soothing in these cases, as well as the practice of voiding urine over a 
vessel containing very hot water. 

If all the above remedies, after patient and persevering use, have 
failed to achieve lasting relief, there remains but one course at our com- 
mand, and that is to remove the constant irritation of the hyperaesthetic 
bladder by making an opening in the vesico-vaginal septum, through 
which the urine can flow without intermission and the bladder have an 
opportunity to regain its normal condition. 

Colpoeystotomy. — This is a very simple operation, and requires no 
special preparation other than is called for in any patient to whom am 
anaesthetic is to be given. The patient is placed in Sims's position, 
his speculum introduced, and a grooved male sound passed into the 
bladder, by means of which the vesico-vaginal septum is put on the 
stretch. At the most prominent point in the median line between the 
neck of the bladder and the cervix uteri — that is, about halfway in the 
space known as trigonum vesicae — a longitudinal incision about an inch 
in length is made with a curved sharp-pointed bistoury, care being taken 
to cut through the mucous membrane of the bladder to the same extent 
as that of the vagina. With catgut sutures and a rather sharply curved 
needle the mucous membrane of the bladder and that of the vagina are 
sewed together, either interrupted or a running underlooped suture being 
used. This is necessary in order to prevent the speedy closure of the 
fistula ; indeed, in spite of this precaution the opening is kept patulous 
with great difficulty, owing to the natural tendency of such wounds to 
contract. The bladder is then washed out through the urethra with a 
mild antiseptic solution, in order to clear it of possible coagula, and if 
thought necessary a soft elastic catheter is passed through the fistula 
into the bladder in order to ensure its remaining open. The bladder 
should then be washed out two or three times daily through the urethra 
with one of the solutions above mentioned, which of course will escape 
through the vagina. The relief experienced from this operation is 
simply marvellous : from the moment of its performance we have seen 
patients sleep quietly, begin to eat and digest well, recover their nerve- 
tone, their flesh, and vitality, and rapidly change from miserable, ema- 
ciated, hysterical, and nervous women to the very reverse. Of course 
it is not pleasant for a woman to have urine constantly dribbling from 
her vagina, which, with the vulva, in course of time will become exco- 
riated in spite of the utmost cleanliness ; but this inconvenience is 
nothing in the minds of these poor sufferers compared to the agony 
which they endured before. The fistula will usually have to be kept 
open for from three to six months, the mucous membrane of the blad- 
der being all the time treated in the manner indicated above until it 
has regained its perfectly healthy condition, when the fistula is closed 
in the manner described in the chapter devoted to that operation. 

Contraction of the Bladder. — As a result of chronic cystitis, 

16 



242 DISEASES OF THE FEMALE URETHRA, ETC. 

the urgent symptoms of which have slowly disappeared and the urine 
become normal, a gradual contraction of the calibre of the bladder at 
times takes place, probably in consequence of the frequent desire to 
empty that organ of the irritating urine. While thus all the other 
signs of chronic cystitis have disappeared, there still remains this one — 
namely, the inability of the bladder to retain more than a few ounces 
of urine. It is not the irritable bladder which accounts for those symp- 
toms, as was the case during the persistence of the cystitis, but the 
contraction of the organ and its much-lessened calibre. Such patients 
are obliged to empty their bladder just as often as during the cystitis, 
and naturally therefore, while not suffering the same amount of pain as 
before, are still in a very uncomfortable position. To overcome this 
contraction we have followed for some years an ingenious plan — which 
was, we believe, first suggested by Braxton Hicks — of gradually increas- 
ing the retentive power of the bladder by accustoming it from day to 
day to retain a slightly increased quantity of warm water. In this 
manner, after a few months a bladder that would not hold more than 
four ounces was brought to hold sixteen to twenty before the patient 
found it necessary to empty it. The water was usually introduced very 
gently from a fountain syringe, and not by means of forcible pressure. 

Incrustation of the Bladder. — As a result of chronic cystitis 
with large deposits of phosphate of lime and other salts, the mucous 
membrane of the bladder may become incrusted with a layer of these 
salts, so that the vesico-vaginal septum may on examination per vagi- 
nam feel almost solid. This may be said to be a preliminary stage to the 
formation of a vesical calculus. We have seen a number of such cases, 
the prominent symptoms of which were the passage of very offensive 
thick urine highly loaded with salts, pus, and mucus, and of course the 
presence of considerable pain. The worst case which we have seen we 
cured by means of the sharp curette, with which we scraped away at 
different intervals all the earthy deposits which were not washed away 
by the subsequent irrigation and spontaneous discharge. By means of 
very frequent irrigation of the bladder we rapidly restored its mucous 
membrane to a healthy condition, at the same time giving mineral acids 
and proper regimen to prevent the re-formation of the excess of salts 
in the urine. 

Stone in the Bladder. — Stone in the bladder is not so common 
in women as in men. Its formation undoubtedly depends upon a pecu- 
liar uric-acid diathesis which may occur even in young girls before the 
age of puberty. As a cause of stone in some of these subjects has been 
found a foreign body, such as a hairpin, a match, or a piece of lead pencil, 
which had been passed into the bladder for purposes of masturbation. 
In one case recently reported in this State a young girl of thirteen had 
introduced a thread spool into the vagina ; this gradually ulcerated into 
the bladder, and there formed the nucleus for a large calculus, which 
was eventually removed per vaginam and the fistula closed. 1 

Reamy has recently reported the removal of a stone weighing 365 
1 Ellison, Am. Journ. Obst, vol. xxii., 1889, p. 144. 



DISEASES OF THE BLADDER. 243 

grains by vaginal cystotomy from a girl seven years of age. Smaller 
stones, if of the softer varieties, can usually be crushed by forceps or 
the lithotrite passed through the urethra, and the detritus washed out 
through the same passage, but larger calculi should certainly be removed 
through an incision in the vesico-vaginal septum, which can either be 
closed at once, or if, as is usually the case, there is cystitis present, 
after the cure of that disease. 

To attempt to draw a stone measuring an inch in diameter through 
a female urethra would probably result in laceration of that canal and 
permanent incontinence — an accident which, according to Emmet, is not 
unlikely to occur even after a dilatation sufficient merely to introduce 
the index finger. We ourselves have often practised such an amount 
of dilatation, without, however, seeing any incontinence, temporary 
or permanent, result. 

Sloughing of the Mucous Membrane of the Bladder from 
Impaction of the Gravid Retroflexed Uterus. — This very pecu- 
liar accident was, we believe, first described by Dr. Brandeis of Louis- 
ville, Ky., some twenty-five years ago. It has since been observed a 
number of times, and is of sufficiently frequent occurrence to justify 
our saying a few words about it. 

The enlargement of the gravid retroflexed and impacted uterus seems 
to interfere with the nutrition of, and circulation in, the bladder ; in 
consequence, gangrene of the most vascular part of the bladder, its 
mucous membrane, takes place, and under great pain, high fever, and 
after severe expulsive efforts the urethra is dilated and the exfoliated 
mucous lining of the organ is extruded or withdrawn by the physician. 
If the patient does not die from the septic infection preceding this 
event, she may recover, although her bladder will probably not be in 
a very normal condition ever afterward, as it is doubtful wheher its 
mucous membrane can be entirely re-formed. Our object in mention- 
ing this rare occurrence is chiefly to let the practitioner bear it in 
mind if he should meet with a doubtful case of the kind. 

Cancer and Other Neoplasms of the Bladder. — Cancer of 
the bladder is usually of the villous variety, and develops as a rule very 
rapidly. Still, cases have been reported where the disease existed for a 
number of years before terminating fatally. Thus Winckel mentions a 
case of his own which lasted thirteen years ; Blichwinge. nineteen 
years; and Hutchinson, six years. Its symptoms are painful mictu- 
rition and frequent discharges of bloody urine. The diagnosis can be 
made best bv dilating; the urethra and introducing the fino-er into the 
organ. Its treatment would consist in scraping away the neoplasm 
with the sharp curette until the bladder-wall is completely smooth. 
Hemorrhage may then be arrested by hot irrigation, by vaginal tam- 
ponade, and the ice-bag over the suprapubic region. A permanent cure 
is of course not to be expected. 

Polypi of the Bladder are composed of the mucous coat, ami the 
muscular tissue is also liable to be thickened. They have been found 
as lar^e as a turkey's e^-o-, having first made themselves known bv a 



244 DISEASES OF THE FEMALE URETHRA, ETC. 

frequent desire to pass water. The diagnosis is of course made by the 
finger per urethram, and the treatment consists in removal, if they are 
of any size, through the vesico-vaginal septum. 

Exstrophy of the Bladder is a congenital affection, and indicates an 
absence of the anterior wall of the bladder and corresponding abdomi- 
nal wall, in consequence of which the interior of the bladder is exposed, 
so that the openings of the ureters can be seen with the urine dribbling 
from them. Of course only a plastic operation, by means of which the 
skin of the abdomen is drawn over the exposed bladder and made to 
replace the missing portion of that viscus, promises any cure for this 
deformity. If this is impossible, nothing can be done but to wear a 
urinal specially fitted for the case. 

Ureters. 

Anatomy. — As is well known, the ureters pass down on either side 
of the cervix uteri about an inch distant from its lateral borders, 
imbedded in cellular tissue, and open into the bladder at two points 
about one and a half inches in front of the cervix and about one inch 
apart. It is claimed by Pawlik, Kelly, Saenger, and some others that 
these tubes can in their normal condition and position nearly always be 
felt by the examining vaginal finger. We have often felt them in this 
manner, but, we confess, have more often failed to find them. They 
are chiefly of importance from a gynecological standpoint in their rela- 
tion to the cervix uteri during the operation of complete removal of the 
uterus per vaginam, and in difficult operations for removal of adherent 
ovarian cysts and uterine fibroids by laparotomy, when they have not 
infrequently been either cut or accidentally included in sutures, in the 
latter instance to the very great detriment of the patient, who usually 
died of uraemia from retention of urine in a kidney of that side, or if 
she survived this danger recovered with a fistula connecting the ureter 
with the vagina or the external skin. 

The only disease of the ureter which we propose to discuss here is 
the inflammation of that duct as a result of chronic cystitis. The 
inflamed and hypertrophied ureter can be felt passing up on either side 
of the cervix until beyond the reach of the vaginal finger. In such 
cases it is exquisitely tender to the touch, and if its topographical rela- 
tions are borne in mind cannot be mistaken for anything else. Several 
such cases have come under our personal observation — one in which the 
left ureter was thus diseased, the inflammation in this instance having 
spread down from the pelvis of the kidney, instead of from the opposite 
direction. At a subsequent autopsy the diagnosis was verified, for the 
left ureter was found in nearly its whole extent hypertrophied to the 
size of the little finger. 

There is of course nothing to be done directly for the diseased 
ureter, which is only a part of the more deep-seated disease in the kid- 
ney. Still, a recognition of the disease of the ureter would lead us in the 
one instance to anticipate and perhaps avert the spread of the disease of 
the bladder upward, and in the other instance cause us to suspect sup- 
puration in the kidney of the affected side. 



URINARY FISTULJE. 245 



CHAPTER XVII. 

FISTULA OF THE FEMALE GENITAL ORGANS. 

Definition. — As a result of certain traumatic and morbid processes 
the continuity of the vaginal and uterine walls may be destroyed and 
communication established with adjacent viscera. To the tracts or pas- 
sages thus opened the name of fistulae has been given. 

Varieties. — These communications connect the vagina or uterus with 
some viscus in immediate proximity, for the natural outlet of which 
they act vicariously, or with some neighboring part, as the peritoneum, 
the vulva, or the pelvic areolar tissue. Their varieties have received 
the following descriptive appellations : 
Urinary Fistulas : 

Vesi co-vaginal fistula ; 
Urethro-vaginal fistula ; 
Vesico-utero- vaginal fistula ; 
Vesico-uterine fistula ; 
Uretero-uterine fistula ; 
Uretero-vaginal fistula. 
Fecal Fistula? : 

Recto-vaginal fistula ; 
Entero-vaginal fistula ; 
Recto-labial fistula. 
Simple Vaginal Fistula?: 
Peritoneo-vaginal fistula ; 
Perineo-vaginal fistula ; 
Blind vaginal fistula. 

Urinary Fistulae. 

Urinary fistulae may occur on any part of the anterior surface of 
the genital canal intervening between the vulva and fundus uteri. Fig. 
112 displays the points at which they are usually observed. 

Vesico- Vaginal Fistula (3) is a communication between the blad- 
der and vagina, either at the trigonum or the base, which may involve 
only enough tissue to admit a small probe or entirely destroy the vesico- 
vaginal wall. Such an opening may be oval, angular, elliptical or 
linear in shape, and its borders may be thick or thin, soft or indurated, 
rough or smooth, pale or vascular. 

Urethro-Vaginal Fistula (4) resembles that just mentioned. 
except in the fact that the destruction of tissue which has produced it 
involves the wall of the urethra, and not that of the bladder. 



246 



FISTULA OF THE FEMALE GENITAL ORGANS. 



Yesico-Uterine Fistula (1) are those in which there is a direct 
communication between the bladder and uterus above the point of 

vaginal attachment. The 
Fig. 112. vagina is consequently not 

involved, and the urine pass- 

; #^JklfifiJ\\^ * n S * nto tne uterus escapes 

at the os. 



Vesico- Uteko-Vaglnal 
Fistula (2) are those in the 
production of which a lesion 
occurs in both uterus and 




Location of Various Forms of Fistulse : 1, vesicoute- 
rine fistula; 2, vesico-utero- vaginal fistula ; 3, vesico- 
vaginal fistula ; 4, urethrovaginal fistula ; 5, recto- 
vaginal fistula ; 6, recto-labial fistula ; 7, fistula in 
ano. 



vagina, as is imperfectly 



shown by 2. At the vagi- 
nal junction there is a per- 
foration of the bladder, but 
this does not penetrate to 
the cavity of the uterus. A 
canal is created in its wall, 
and through this the urine es- 
capes into the vagina. The 
last two forms of fistulse were 
first accurately described by 
Jobert, who made of the last 
two varieties, superficial and 
deep. In the first a canal is 
channelled out on the vesical surface of the cervix uteri ; in the second 
the cervix is to a greater or less extent destroyed by the process of 
sloughing, and through it the urine passes. In the first form the 
lesion is chiefly vesical and uterine, the vagina not being much 
injured; in the other it affects three organs, the bladder, the uterus, 
and the vagina. All these forms of fistulse may thus be grouped into 
classes : 

1st Class. Those involving the urethra ; 
2d Class. Those involving the base of the bladder ; 
3d Class. Those involving the uterus : 
4th Class. Those involving the ureters. 
In some cases, however, multiple fistulse exist, and no special classi- 
fication can be made. 



Causes. — Any influence which is capable of destroying the con- 
tinuity of the vaginal walls, either by mechanical, chemical, or vital 
action, would of course give rise to this condition. Those which are 
found in actual practice to have proved most commonly efficient are the 
following : 

1st. Prolonged or very severe pressure ; 

2d. Direct injury ; 

3d. Ulceration or abscess. 
Pressure, which is more frequently a cause than any of the others 
mentioned, is generally produced by the child's head remaining too 



URINA B Y FISTULJE—CA USES. 247 

long in the pelvis during labor. This is beyond doubt the most pro- 
lific source of the accident, though it may also attend a rapid labor in 
which the vagina has been pressed against some point of the pelvis 
with great violence. Such pressure produces sloughing of the part of 
the vagina receiving it, and at that spot a deficiency of tissue in future 
exists, which constitutes a fistula. The process of sloughing occurs 
from pressure of the foetal head, exactly as a bed-sore takes place in 
one who lies for too long a time in the same position, the sequence 
being disturbed and retarded circulation, impaired nutrition, and local 
death. Or a puerperal vaginitis may be established, which runs a 
violent course and may end in sloughing after several weeks' duration. 

An involuntary flow of urine usually announces the existence of a 
fistula within three or four days after delivery, though when it is the 
result of injury inflicted by instruments employed in delivery it may 
occur immediately. On the other hand, the separation of the slough, 
which will entail deficiency of tissue and its results, may not take 
place until much later, when perhaps all fears are allayed and the case 
is regarded as progressing favorably. Jean Louis Petit records one 
case developing in symptoms after a month ; Jobert, one in which on 
the twenty-second day after delivery the slough was found at the mouth 
of the vagina ; Adler of Iowa, one in which after twenty-nine days 
the slough was only partially separated ; and Agnew of Philadelphia, 
another in which it separated on the twenty-first day. 

Other agencies which may create fistulse, but which have been 
rarely noticed to do so, are pessaries, stones in the bladder, fecal accu- 
mulation, etc. Recently a case was sent to us in which repeated vagi- 
nal galvano-puncture of a fibroid tumor produced a slough of the 
vaginal and vesical walls and a fistula, which we closed by suture 
after the attending physician had made three ineffectual attempts. 

Direct injury may produce the accident by contusing or lacerating 
the vaginal walls, as may occur during delivery by the forceps or crani- 
otomy. That these operations, when carelessly or unskilfully performed, 
may produce a fistula no one will pretend to deny, but there can, with 
the evidence now recorded, be no doubt that they have often been cred- 
ited with unfortunate results which were in reality due to tardiness in 
their employment. Very often, where a labor has been allowed to be 
prolonged in the second stage until the vitality of certain points in the 
vagina has become irremediably impaired, and the process of sloughing 
has been already inaugurated, subsequent delivery by forceps or crani- 
otomy has been regarded as producing fistula. Under such circumstances 
the real morbid agency, prolonged and violent pressure, is lost sight of. 
and the more palpable agents, the instruments employed, are viewed 
as the source of the accident. The truth with reference to this point 
should be well understood by every practitioner, for unless it be so an 
incompetent person may shield himself from merited blame by casting 
censure upon a consulting physician by whose efforts the lives of both 
mother and child have been saved, or a skilful operator may suffer 
unjustly in a suit for malpractice. 

In a report upon this subject by Mr. I. Baker Brown 1 to the Obstet- 

1 Obstet. Tmns., vol. v. p. 23. 



248 FISTULjE of the female genital organs. 

rical Society of London in 1863 the following statements are made : 
" With regard to the causes of vesico-vaginal fistula, of the 58 cases 
admitted into the London Surgical Home, 47 were over twenty-four 
hours in labor, and 89 were as much as thirty-six hours or more ; 7 were 
two days ; 16 were three days ; 3 were four days ; 2 were five days ; 
2 six days ; and 1 seven days. 

"In the whole number of cases instruments were used in 29, exactly 
one-half, and in 4 only of these was the labor less than twenty-four 
hours ; and with seven exceptions the patient had been thirty-six hours 
or more in labor before instruments were used. 

" Of the 58 cases, in 24 only the injury happened at the first labor ; 
in 7 at the second ; in 5 at the third ; in 4 at the fourth ; in 6 at the 
fifth ; in 2 at the sixth ; in 5 at the eighth ; in 1 at the ninth ; 1 at the 
thirteenth ; 1 at the fifteenth ; and 2 not mentioned. 

" From the foregoing statistics it is evident that the cause of the 
lesion is protracted labor, and not the use of the instruments or deform- 
ity of the pelvis. 

"As a necessary deduction from what has been stated, it follows that 
vesico-vaginal fistula would scarcely if ever occur if a labor were not 
allowed to become protracted ; and this is a point for the careful 
consideration of practitioners in midwifery." 

The experience of Dr. Sims 1 is confirmatory of that of Mr. Brown. 
Emmet, whose authority in this matter is very high, gives the causes 
of 179 cases, 2 and 171 of the number originated in childbirth. 

It may be said in a general way, then, that the cause of urinary 
fistula in the female is parturition, a few exceptions to the rule occur- 
ring ; that protracted labor is very generally productive of them; 
and that the prompt use of instruments is, as a rule, preventive 
of them. 

It is a curious fact that when, for the relief of chronic cystitis, a 
vesico-vaginal fistula is intentionally created by the knife, it is difficult 
to keep it open. In spite of the occasional introduction of the sound 
for this purpose, such openings obstinately heal of their own accord, so 
that it becomes necessary to place a species of button or stud in the 
opening to prevent an issue which under these circumstances is unde- 
sirable. This case seems parallel with that of perforation of the tympa- 
num, which, being effected by an instrument, heals rapidly ; while the 
closure of an opening, the result of disease, is usually impossible. 

About thirty years ago Dieffenbach 3 recorded a case of vesico-vagi- 

J J CD O 

nal fistula, the cause of which had been the presence of a stone in 
the bladder complicating labor ; and Baker Brown 4 mentions another 
instance of this kind in 1861. 

Ulceration or Abscess. — The vaginal walls may be eaten through 
by cancerous, syphilitic, or phagedenic ulcers, or a communication may 

1 Gardner's Notes to Scanzoni, p. 503. 

2 Principles and Practices of Gynecology. The author gives in his tables 202 cases, but 
we subtract 23 which were intentionally produced for removal of stone and cure of cysti- 
tis. Evidentlv these are not admissible in the study of etiology. 

3 Med. Record, vol. i. 321. 4 Op. cit. 



URINARY FISTULJE— SYMPTOMS. 249 

be established by an abscess opening into the vagina and into a neigh- 
boring viscus or part. In one case we found, in the autopsy of a woman 
who had died from a profuse diarrhoea in which the feces had passed by 
the vagina, a communication created by abscess between the caput coli 
and that canal. 

Cancerous disease often destroys the vesico-vaginal septum, but as 
these fistula are irremediable and attend upon a rapidly fatal disorder, 
they attract little attention in themselves. Lastly, certain diseases pro- 
ducing deficiency of nutrition — as, for example, the continued fevers — 
may cause sloughing of the vaginal walls or phagedenic ulceration. 

Sympto?ns. — The prominent symptoms and signs of urinary fistulse 
may be grouped under three heads : first, those furnished by a charac- 
teristic discharge ; second, those arising from the irritant action of such 
discharge upon the part over which it flows ; and, third, those afforded 
by physical examination. 

Sometimes the escape of urine is so excessive as to preclude the 
necessity of a discharge per vias naturales ; at others the excretion is 
partly evacuated by the natural and partly by the vicarious outlet. 
This symptom shows at times eccentric variations. When the fistula 
is seated in the urethra, the bladder may be distended without loss, 
which may take place into the vagina during micturition. Sometimes 
while in the horizontal posture the escape will cease, the anterior vesi- 
cal wall being pressed by the intestines against the fundus so as to 
close the opening ; and in other cases, where the fistula is above the 
orifice of the ureters, the flow will take place while the patient lies, 
and cease when she stands. 

The passage of excrementitious material through a canal and over 
a tissue not intended by nature to tolerate it produces inflammatory 
action, pruritus, eruptions, and excessive irritability. In urinary fistulse 
the vulva and thighs are usually red, excoriated, and covered by a 
vesicular eruption. The vagina is sometimes covered by urinary con- 
cretions, and a highly offensive odor emanates from the patient's body. 

The general health is very likely in time to give way, and hysteria, 
chlorosis, and graver disorders often show themselves. 

Physical Signs. — If the fistulous orifice be a large one, even a 
superficial examination by touch, the patient lying upon her back, will 
generally serve to reveal the nature and extent of the lesion. It is 
different, however, with very small fistulae, which will sometimes elude 
the most careful investigation. For their detection Sims's speculum 
should be employed, and in many cases it will be found advisable to 
place the woman in the knee-elbow position, instead of that on the side, 
before its introduction, and to have the buttocks and labia pulled apart 
by the hands of assistants. Even this method is not effectual in reveal- 
ing the opening if it be very minute. Under these circumstances the 
bladder should be injected with water, and its escape into the vagina 
carefully watched for. Sometimes by this means a capillary opening- 
just at the junction of the vagina and cervix will be detected. 
Kiwisch, Meyer, Veit, and others have used for this purpose water 
colored with substances which will impart a bright tinge to it. Infu- 
sion of India ink, cochineal, madder, indigo, or plain milk may be 



250 FISTULJE OF THE FEMALE GENITAL ORGANS. 

thus employed. The opening being once detected, the probe and finger 
Avill readily reveal the course, extent, and terminus of the tract. 

Complications. — The complications which these fistulae develop are 
vaginitis, vulvitis, stricture of urethra and vagina, and sometimes endo- 
metritis and peri-uterine inflammation. The most constant and import- 
ant of these is the formation of bands which contract the vagina, and 
which often require severance before operative procedure can be prac- 
tised. 

Prognosis. — Previous to the year 1852 the prognosis of all cases 
in which the orifice acted as a vicarious outlet — for example, vesico- 
vaginal, recto-vaginal, and vesico-utero-vaginal fistula — was eminently 
unfavorable, for they very rarely undergo spontaneous recovery, and the 
means of cure at our command up to that time were uncertain and full 
of discouragement. In 1860, Dr. Sims 1 stated: "Of 261 cases of 
vaginal fistula (vesical and rectal), 216 have been permanently cured by 
the silver-wire suture, 36 are curable, and 9 incurable. Every case is 
curable when the operation is practicable, provided there is no consti- 
tutional vice to interfere with the powers of union. Success is the rule, 
failure the exception." 

The enlarged experience of the profession has fully corroborated 
these assertions, made thirty years ago, and it may now be accepted as 
a true statement as to the prognosis of all fistulas of the female genital 
organs, except cases of vesico-uterine fistula, in which the point of 
rupture is out of reach of surgical interference. 

History. — The history of this subject dates back only to the six- 
teenth century, when attention was called to it and a plan of treatment 
proposed by Ambrose Pare. Before the discovery of the forceps the 
accident must have been one of very frequent occurrence, for then 
powerless labor was not under the control of the obstetrician, except 
by resort to a set of badly-constructed instruments for craniotomy, 
which in themselves presented serious dangers of laceration. The 
symptoms which mark its existence are so palpable and distressing that 
it does not require a physician to diagnosticate it, and no case of any 
gravity could have escaped notice. And yet, curious to relate, there 
are few diseases to which woman is liable which have received so little 
notice at the hands of the ancients. Even pelvic cellulitis and other 
affections, which have but lately attracted attention from the physicians 
of our day, are distinctly alluded to by the writers of the Greek school ; 
but this one, so annoying, so destructive of happiness, and so urgent in 
its demands for relief, has received scarcely any mention. It is true 
that Hippocrates makes some slight allusion to involuntary discharge 
of urine following difficult labors, but his remarks upon the condition 
are meagre and unimportant. 

We do not claim to have made a full examination of the writings of 
the Greeks and Romans with reference to the subject, but base the 
statement which we have advanced chiefly upon the fact that the two 
great compilers of their periods, Aetius and Paulus iEgineta, make no 
mention of it. The work of Aetius upon diseases of women (Tetra- 
biblos IV.) is made up of quotations from Soranus, Aspasia, Galen, 

1 Gardner's Notes to Scanzoni, p. 515. 



UBINARY FISTULA— HISTORY. 251 

Philumenus, Archigenes, Leonidas, Rufus, Philagrius, Asclepiades — in 
fact, of all worthy of note whose writings were stored in the Alexan- 
drian Library, which was the seat of his labors. By none of these is 
mention made of the affection. The works of Paul of iEgina, enriched 
as they have been by the copious notes of Dr. Adams, their translator, 
are equally silent ; and the researches of those who have examined the 
writings of the Arabians record no discovery of any description of it at 
their hands. At any rate, it is quite certain that no contributions to 
the treatment of the difficulty were made by the writers of the Greek, 
Roman, or Arabian school. 

Beginning at the seventeenth century, we allude only to those who 
have made some advance in treatment, and do not endeavor to record 
the names of all who have reported cures or advised procedures which 
have not been of subsequent utility. 

Before proceeding with the historical sketch which ensues, we would 
draw the attention of the reader to two interesting facts which it will 
demonstrate : It will be seen that for centuries steady, persevering, and 
systematic efforts have been made to render this revolting malady 
curable, and that, as has often been the case in other great discoveries, 
the minds of several investigators pursued the same course until at last 
success was reached. After a discovery has been made it is always 
easy to point out the elements upon which it rests for its success, and 
even to follow the process of reasoning by which each in turn was 
supplied. There can be no doubt that the three elements necessary 
for successful treatment of the lesion which we are considering 
were — 

1st. A means for exposing the fistula to view and manipulation ; 

2d. A suture which would remain in place without causing inflam- 
mation ; 

3d. A means of disposing of the urine during the process of cure. 

From the time that Pare" suggested a plan of treatment it will be 
noticed that surgeons brought these three means of cure to their aid. 
But they employed them separately, some using one of them, some 
another, and others still combining two. It was not, however, till the 
time of Gosset, in 1834, that the three were combined by the same 
operator. 

In 1570, Ambrose Pare' proposed the closure of vesico- vaginal 
fistulse by a retinaculum. In 1660, Roonhuysen of Amsterdam used 
a speculum, through which he pared the edges of fistulse and united 
them by a needle. In 1720, Voelter of Wurtemberg advised a needle, 
needle-holder, suture by silk or hemp, and a catheter. In 1792. 
Fatio of Basle operated by twisted suture, placing his patients in the 
lithotomy position. In 1804, Dessault used a vaginal plug and cathe- 
ter in the bladder. In 1812, Naegele of Wurtemberg scarified the 
edges by scissors, used needles to approximate them, and employed the 
interrupted suture. In 1817, Schreger of Germany placed the patient 
on the abdomen, scarified the edges, and used interrupted suture. In 
1825, Lallemand of France applied nitrate oi' silver to the edges oi' 
the fistula, and approximated them by a "sonde erigne" passed 
throuo;h the bladder, and of 1-"> cases, cured 4. In 1829, Roux oi' 



252 FISTULJE OF THE FEMALE GENTTAL ORGANS. 

France tried twisted suture with metallic bars and ordinary thread. 
In 1834, Gosset of London combined the knee-elbow position, leva- 
tor perinei speculum, metallic sutures, and catheter permanently kept 
in the bladder. In 1836, Beaumont 1 employed the quilled or clamp 
suture. In 1837, Jobert de Lamballe resorted to autoplasty, trans- 
planting a piece from the labia, buttocks, or thighs. In 1838, Wutzer 
of Bonn placed his patients on the abdomen, pared the edges of the 
fistula, and approximated them by insect needles and figure-of-8 suture. 
To expose the fistula the perineum was held up by a hook and the labia 
drawn aside by assistants. In 1839 and 1840, Hayward of Boston, 
U. S., reported three cases cured by vivifying the edges and closing 
with silk suture. This surgeon introduced a notable improvement, 
and aided in the final success by vivifying not only the borders of 
the fistula, but the neighboring vaginal surfaces. In 1844, Chelius 2 
placed his patients in the knee-elbow position. In 1846, Metzler 3 of 
Prague employed the levator perinei speculum, perforated balls the 
size of shot, the knee-elbow position, gilded needles, and a permanent 
catheter. In 1847, Mettauer of Virginia employed the catheter and 
leaden sutures with such success that he was led to make the following 
statement: " I am decidedly of the opinion that every case of vesico- 
vaginal fistula can be cured, and my success justifies the opinion." 
In 1852, Jobert de Lamballe adopted his method, styled "reunion 
autoplastique par glissement," which consisted in giving sufficient vagi- 
nal tissue for union by cutting transversely through the vagina at its 
junction with the uterus, in a line with the fistula. In 1852, Marion 
Sims 4 of the LTnited States combined the three essentials for success — 
the speculum, the suture, and the catheter — and placed the operation 
at the disposal of the profession. 

The discoveries to which he laid special claim were these : 

1st. A method by which the vagina could be distended and 
explored ; 

2d. A suture not liable to excite inflammation or ulceration ; 

3d. A method of keeping the bladder empty during the process of 
cure. 

Entering the field almost as early as Sims, Simon of Germany 
greatly aided in systematizing the operation, and has been second to 
no one else in improving it. 

From a study of the literature of the subject it is made as evident 
as written testimony can make any history of the past that not only 
did several investigators combine two of these elements of success in 
their operations, but that two, Gosset in England, and twelve years 
afterward Metzler in Germany, absolutely combined all three. It is 
also made equally evident that they either failed to recognize the 
importance of what they had attained, or did not impress its value 
upon others so that humanity could profit by it. Dr. Gosset's pro- 
cedure is thus described in his own words in the first volume of the 
London Lancet, page 346 : 

" Having placed the patient, resting upon her knees and elbows, 

1 Med, Gaz., Dec. 3, 1836, p. 355. 2 Agnew, op. tit, p. 15. 

3 Schuppert on Ves.-Vag. Fistula, p. 41. 4 Amer. Journ. Med. Sci., 1852. 



URINARY FISTULJE— HISTORY. 253 

upon a firm table of convenient height covered with a folded blanket, 
the external parts were separated as much as possible by a couple of 
assistants, so as to bring the fistula, which was immediately above the 
neck of the bladder, into view. I seized with a hook the upper part 
of the thickened edge of the bladder which surrounded the opening, 
and proceeded with a spear-shaped knife to remove an elliptical por- 
tion, which included the whole of the callous lip surrounding the fis- 
tula, the long angle of the ellipsis being transversely. This was 
readily effected ; but in consequence of the very contracted state of 
the parts the next steps of the operation were with difficulty executed ; 
and I should not have succeeded in passing the sutures had I not used 
needles very much curved and a needle-holder which I could disengage 
at pleasure, the needles being withdrawn with a pair of dissecting-for- 
ceps after the holder was removed. In this way three sutures were 
passed ; and afterward, by twisting the wire, the incised edges were 
brought into contact and retained in complete apposition until they 
had firmly united. One of the sutures was removed at the end of the 
ninth day, the second at the end of the twelfth day, and the third was 
allowed to remain until three weeks had elapsed. After the operation 
the patient was put to bed and desired to lie on her face, an elastic 
gum catheter, having a bladder secured to its extremity for the recep- 
tion of the urine, having been introduced and retained by means of 
tapes. She had not the slightest discharge of urine through the vagina 
after the operation, which completely succeeded in restoring the healthy 
functions of the part. The advantages of the gilt-wire suture are 
these : It excites but little irritation, and does not appear to induce 
ulceration with the same rapidity as silk or any other material with 
which I am acquainted ; indeed, it produces scarcely any such effect, 
except when the parts brought together are much stretched. You can 
therefore keep the edges of a wound in close contact for an indefinite 
length of time, by which the chances of union are greatly increased. 
I have used it now in very many operations, as after extirpation of the 
breasts, tumors of various kinds, and for bringing the lips together 
after the removal of a cancerous growth, in all of which cases it answered 
extremely well." 

The method of Metzler was published in the Prague Viertel 
Jahresselirift for 1846 under the title of " Pathology and Treatment 
of Urinary and Vesico-Vaginal Fistulas, with a method of treatment 
easily executed and completely successful." We transcribe his article 
from the brochure of Dr. Schuppert, already alluded to : 

" To perform the operation successfully it is of much importance 
to have — first, a speculum, serving as a dilator of the vagina. Such 
an instrument consists of a grooved conical blade, five and a half inches 
long, three inches wide at the anterior part, half an inch wide at the 
posterior. The end of the speculum is bent under at a right angle and 
protected with wood for the handle. The instrument is best when made 
of silver, and polished to reflect the light on the parts to be opera toil 
upon. Second, an apparatus consisting of perforated clamps, gilded 
needles, and an instrument called ' Rosenkranzwerkzeug,' consisting oi' 
perforated balls of the size of a large shot, by which the clamps are held 



254 FISTULA OF THE FEMALE GENITAL ORGANS. 

in contact. After the patient is placed on her knees and elbows, the 
dilator is introduced into the vagina and given to an assistant, who in 
holding it presses it against the rectum. The edges of the fistula are 
then pared off, which may be accomplished with curved scissors. One 
line and a half from the mucous membrane of the vagina and half a 
line from the edge of the bladder have to be cut off; the needles are 
then applied, and the wound held in coaptation by the clamps ; a female 
catheter is introduced into the bladder by the urethra, and the catheter 
fastened by a T bandage." 

From what has been said thus far it would appear that Dr. Sims 
was forestalled in all the details of the discovery by which he has ren- 
dered vaginal fistula curable. To a certain extent this is unquestion- 
ably true, but only as regards the theory of the matter. Before his 
publications the unfortunate women whose lives were rendered miserable 
by fistula through the vaginal wall were virtually almost as hopelessly 
affected as they were before Gosset and Metzler appeared in the field. 

Velpeau 1 in 1839 thus speaks of cure of these fistulae : " To abrade 
the borders of an opening when we do not know where to grasp them ; 
to shut it up by means of needles or thread when we have no point 
apparently to secure them ; to act upon a movable partition placed 
between two cavities hidden from our sight, and upon which we can 
scarcely find any purchase, — seems to be calculated to have no other 
result than to cause unnecessary suffering to the patient." Vidal de 
Cassis 2 says : " I do not believe that there exists in the science of sur- 
gery a well-authenticated, complete cure of vesico- vaginal fistula." 
Malgaigne 3 in 1854 says: "But the truly rational method, that which 
at present offers the greatest facility and efficacy, and the only one 
which should be applied in all cases of fistula of large size, is the 
suture by the procedure of Jobert." 

Wutzer reported the following as the statistics which he had col- 
lected: 4 "20 cases of vesico-vaginal fistula were subjected to 48 ope- 
rations — among which were elytroplasty, episiorraphy, cauterization, 
sutures, interrupted or twisted, and both — and only 2 cured!" 

This was the real state of science with reference to this opprobrium 
chirurgice when Marion Sims, by combining and utilizing the three 
essentials for success, gained it, and rendered the operation practicable 
for all surgeons. It must not be supposed that he availed himself of 
the results obtained by his predecessors. All that he attained was 
arrived at by hard and original labor. Indeed, no one can read his 
address upon "Silver Sutures in Surgery," delivered before the New 
York Academy of Medicine in 1857, without being struck by his want 
of familiarity with the antecedent literature of the subject of his dis- 
course. 

We would not be understood as claiming for America in this matter 
more than she really deserves — the establishment of the method of cure 
upon a firm and certain basis. To claim more than this would be to 
ignore the plain teaching of history. To France belongs the inception ; 
to England the glory of having absolutely made the discovery, although 

1 Operative Surgery. 2 Pathologie externe. 

3 Manual de Med. operat. i Med. Record, vol. i. p. 322. 



URINARY FISTULJE— TREATMENT. 255 

she did not appreciate the fact ; to Germany, next to America, the 
credit of having specially advanced and perfected reliable operative 
procedures. In that country to-day, by the method of Simon, success 
even in the gravest cases has become the rule, and failure the rare 
exception. 

Since the first publication of Sims's method numerous modifications 
of it have been put into practice both in this country and Europe, and 
Dr. Sims himself had in his later years altered his plan of operating 
very much. The principle which he demonstrated is, however, the 
same, and the modifications of the operation all act in developing it. 

In this country the operation is commonly performed, not by spe- 
cialists alone, but by practitioners in every walk of the profession, and, 
thanks to the extreme simplicity of Sims's procedure, it is no longer 
looked upon as a difficult undertaking requiring special skill and expe- 
rience. In consequence of improved rules as regards the early use of 
the obstetric forceps, and the better obstetric education now enjoyed 
by the majority of our students, vesico-vaginal fistulae are less common 
than formerly, and it is only in our larger gynecological clinics that any 
number of such operations are now performed. 

Means of Obtaining a Natural Cure. — Within a few days after deliv- 
ery the obstetrician is generally made aware of the existence of vesico- 
vaginal fistula by a steady and involuntary dripping of urine. As soon 
as this is evident a Sims stationary catheter should be placed in the 
bladder, the vagina frequently syringed out with warm water to lessen 
inflammatory action, and the patient kept in the abdominal decubitus, 
in order that a repair of the injury may be accomplished by the efforts 
of Nature. This is all that can be done at this time, for it is too early 
to resort to suture, and the lochial discharge w r ould be interfered with 
by a tampon intended to aid in the cure. The operation by suture 
should not be undertaken before the immediate results of parturition 
have passed off and the fistula has assumed a permanent size and cha- 
racter. 

Treatment. — The methods at our command for curing, or, where cure 
is impossible, obviating the inconveniences due to, fistula of the female 
urinary apparatus, are — 
1st. Cauterization ; 
2d. Suture ; 
3d. Elytroplasty ; 
4th. Occlusion of the vagina or uterus. 

Cauterization. — This once-favorite method of treating all varieties of 
these fistulae has now very deservedly fallen into disuse under the influence 
of improved methods by suture. Malgaigne probably gives this means 
its proper place when he declares that it should be employed only in 
those cases where the fistula is scarcely perceptible. Even in such eases 
Sims's operation is far preferable, and cauterization should be employed 
only where some special circumstance, such as want of skill or of the 
proper instruments, forces the operator to resort to it. The performance 
of it is very simple. Sims's speculum being passed so as to expose the 
fistulous spot, its borders should be thoroughly touched with a pointed 
stick of nitrate of silver or the actual cautery. This should not be 



256 FISTULJE OF THE FEMALE GENITAL ORGANS. 

repeated before the slough created has separated and an opportunity been 
allowed for granulation to fill up the opening. 

To check the flow of urine through the fistulous orifice and support 
the vaginal and vesical walls during the process of granulation, a small 
tampon of cotton, a Gariel's air-pessary, or a glass vaginal plug should 
be kept in the vagina, and, to prevent distension of the bladder a sig- 
moid or soft-rubber catheter should be permanently retained. 

Suture. 

Preparation of the Patient. — No operation in surgery more urgently 
demands a good constitutional condition as an element of success than 
this. Should the patient's health not be good and her blood-state be 
abnormal, a visit to the country, exercise, and fresh air, with vegetable 
and mineral tonics, will do a great deal toward avoidance of failure. 
At the same time, the vagina should be regularly syringed with warm 
water to overcome local inflammation and ensure cleanliness. Should 
the disorder which caused the destruction of the vaginal wall have pro- 
duced as a complication cicatricial bands in the canal, these should be 
cut from time to time, and allowed to heal over a glass vaginal plug, 
and if contraction have taken place in the urethra, it should be over- 
come by bougies. Before the time of the operation the bowels should 
be thoroughly evacuated by a cathartic, and on the clay of its perform- 
ance very little food should be taken, for fear that the long-continued 
use of an anaesthetic might produce vomiting, which would tear out the 
sutures. 

Sims' 's Operation. — This operation may be divided into three parts : 
1st. Paring the edges of the fistula ; 
2d. Passing sutures through them ; 
3d. Approximating them and securing the sutures. 

The patient is anaesthetized and placed on the operating table in 
Sims's position, and the fistula exposed through Sims's speculum. 

The operator, having, near him all the instruments, etc. which he 
will require, places his assistants thus : one holds the speculum, another 
administers the anaesthetic, and a third stands ready at his right hand 
to remove the blood accumulating in the vagina by means of sponges in 
the sponge-holders (Fig. 116), which are rapidly washed in a basin of 
water that stands by his side to be used again. A fourth assistant, if 

Fig. 113. 




Curved Scissors. 



attainable, may be well employed in handing the instruments as they 
are required. All being ready, he proceeds with the first of the ope- 
ration. 



URINAR Y FISTULjE—TREA TMENT. 



257 



Paring of the Edges of the Fistula. — The edge of the fistula, at the 
point which is deemed most difficult of access and manipulation, is 
caught by the tenaculum, or, with what we much prefer, the tooth-for- 
ceps, shown in Fig. 77, and held up. Then with a pair of long-handled 
scissors (Fig. 113) or a knife a strip is cut extending from the mucous 
membrane of the bladder to that of the vagina, care being taken not 
to wound the former. 



Fig. 114. 




Fig. 116. 



Method of Paring the Edges with 
Scissors. 



Fig. 115. 



Showing Bevelling of Edges : a, vesi- 
cal border ; b, vaginal border; c c, 
incision. 




Sims's Sponge-holder, with handle 
nine inches long. 



Another portion of the edge is then seized, and removed like the 
first. The wound thus left should be one bevelled from the vesical 
surface outward, and great care should be observed to remove the 
entire border, for upon this success depends. 

It is of great moment that sufficient tissue should be removed, and 
that the amount taken on the vaginal surface should be greater than 
that near the vesical. 

The abraded surface, from the edge of the fistula to the point of 
vaginal section, should measure at least four lines, or one-third of an 
inch, while above it should just touch the vesical border, not invading 
its mucous membrane. This is made evident by Fig. 115. During this 
part of the operation the sponges, held in long-handled sponge-holders, 
will have to be freely resorted to, but the bleeding generally soon ceases, 
and the operator may proceed to the second step. 

Passing the Sutures. — The sutures are passed by means of slightly- 
curved needles held in a pair of strong forceps (Fig. 117) made for the 
purpose. In some cases the metallic thread, made of annealed silver, 
which is employed, may be passed at once, but usually silk threads are 
first passed, and the silver sutures are attached and drawn through. 

The needles which we employ in the Woman's Hospital are about 
17 



258 FISTULA OF THE FEMALE GENITAL ORGANS. 



three-quarters of an inch long, round, slightly curved, and without cut- 
ting edges anywhere. Dr. John T. Hodgen of St. Louis has invented 
a needle which serves an excellent purpose. It is a very small, straight, 
short needle, with a point like that of a trocar. This passes readily 
through the tissses, and to it is attached a delicate silk thread which 
carries the silver wire, the bent end of which is rubbed down very small 
by sand-paper. The needle, held in the grasp of the needle-holder, 
should be passed at the angle of the wound which is most difficult of 
access, half an inch from the edge of the incision, and brought out at 
the vesical surface, but not involving its mucous lining. Fig. 118 rep- 
resents the point of entrance and exit of the needle. 

The point of the needle having passed out, it is engaged by a tenac- 
ulum or counter-pressure hook (Fig. 119) until it can be seized and 





Course of the needle : a, vesical border ; b, vaginal 
border ; c, point of entrance of needle ; d, point 
of exit of needle. 



Sims's Needle-holder, with Needle 
(Sims). 



drawn through by the needle-forceps. 
Then it is plunged into the other lip and 
drawn out half an inch from the edge of 
the incision. The ends of the silk suture 
are then given into the charge of the as- 
sistant holding the speculum, and another 
is passed in the same way at the distance 
of one-sixth of an inch from the first. In 
this way a sufficient number are passed 
to close the fistula. 

During this procedure the edge of the 
fistula is to be fixed by the tenaculum, 
and should firm, opposing force be needed 
to make the needles pass, it may be given 
by that instrument or by the counter- 
pressure hook shown in Fig. 119. 

When the needle is seized by the for- 
ceps and pulled so as to make the thread 
follow it, some opposing force is needed 
or the thread might cut through the 
tissues. This force is offered by the 
counter-pressure hook, which is put as 
at its point of exit and made to sustain 



a fulcrum under the thread 
and draw it through. 

A bit of silver wire about twelve inches long is attached, by bend- 
ing its extremity, to the first silk suture, and by the use of the fork 
just mentioned the silk thread is drawn through so as to make the wire 



URINA B Y FIST UL2E— THE A TMENT. 



259 



replace it. The silk is then cut off, the silver suture put aside, and the 
operator proceeds to replace each silk thread in the same way. This 



Fro. 119. 

Munde's Counter-pressure Hook. 



being accomplished, the instruments are then changed in order to effect 



the twisting of the sutures 



Fig. 120. 




Twisting the Sutures. 

The ends of the silver sutures being drawn together by the fingers 
and the edges of the wound carefully approximated, each thread is 

Fig. 121. 



Shield for Twisting Wire Sutures. 



slightly twisted so as to keep the whole in apposition. Then the ends 
of the first suture are seized in the bite of the forceps, slipped into the 



260 



FISTULA OF THE FEMALE GENITAL ORGANS. 



Fig. 122. 



fulcrum, and torsion is made so as to close the wound completely at this 
point. In this way the sutures are twisted one after the other, care 
being taken not to carry the torsion so far as to strangulate the tissues 
engaged in the constricting loop. Each suture is then clipped by a 
pair of scissors about half an inch from the edge of the fistula, and 
by means of forceps pressed flat against the vaginal wall, so as not 
to wound the opposite surface. 

The bladder should then be syringed out to remove all blood which 
may have accumulated there ; for if a large clot should be retained in 
this viscus it may cause severe vesical tenesmus, and smaller ones may 
block up the mouth of the catheter, which is to be kept in place per- 
manently, and call for its repeated removal. 

The patient is then placed in bed by the assistants, an opiate is 
administered, and a Sims's sigmoid catheter is passed into the bladder 
and left there. The mouth of this instrument pro- 
jects beyond the vulva, so that under it a small 
china dish may be placed which will receive the 
urine as it passes through. 

We have been in the habit for some years of 
using instead a soft-rubber catheter, w T hich we usually 
remove after five or six days, and thenceforth allow 
the patient to urinate spontaneously. 

The nurse should examine the catheter every two 
or three hours to be certain of its perviousness and 
to remove the urine which collects in the receptacle 
placed under it. 

Once in every twenty -four hours the vagina should 
be syringed out with tepid water, or w T ith this and 
white castile soap or any similar detergent ; but the 
bladder requires no further washing than that men- 
tioned, except in cases of vesical tenesmus. The 
bowels should be kept free by mild laxatives or 
enemas. The diet should be governed by the same 
rules which guide us in the management of patients 
under other surgical operations. It should be nutri- 
tious and unstimulating. 

In from eight to fourteen days the sutures should be removed. Dr. 
Sims declares that "it is unnecessary to allow the wires to remain 
longer than the eighth day;" but others, calculating upon the innocu- 
ousness of metallic substances in the tissues, have left them longer. 
In two of Dr. Schuppert's cases a leaking was detected when the blad- 
der was injected on the sixth and seventh days, which had disappeared 
entirely on the twelfth, when the sutures were removed, and the cure 
was found complete. 

To accomplish the removal of the sutures the twisted end of one 
of them should be seized by a pair of forceps and drawn upon gently 
until the edge of the loop emerges from the tissues in which it has been 
imbedded. Then the blade of a pair of scissors should be inserted 
into the loop and one side cut, after which a little traction will 
remove the suture. 




Shouldering Sutures. 



URINA R Y FIST VLM- TREA TMENT. 



261 



An examination may then, with great caution, be instituted to 
ascertain whether success or failure has attended the operation. A 
visual examination will generally determine this. Should there be any 



Fig. 123. 




Emmet's Twisting Forceps. 

doubt, the bladder may be filled very cautiously with tepid water to 
settle the question as to the entire closure of the fistula. Sometimes 
one operation fails to cure, although it diminishes the size of the 
fistula very much, and subsequent operations must be resorted to. It 
may be necessary to repeat these very frequently before success is 
attained. 

The operation of Dr. Sims has been variously altered in all its steps, 
so that now the number of modifications is quite great — so great, indeed, 
that it would be out of the province of a work like this to mention 



Fig. 124. 



Fig. 125. 





Sims's Sigmoid Catheter. 



Fig. 126. 




Sims's Catheter, new style. 



Soft-rubber Catheter. 



them in detail. In his early operations Dr. Sims employed the quill 
suture, which he called the clamp suture, but a tendency on the part of 
the little metallic bars which he used in place of quills to produce 
ulceration induced him to resort to the interrupted suture. 

Other methods have been successfully employed by Bozeman, Agnew, 
Baker Brown, Simpson, Simon, and others. For fear of being uselessly 
prolix we shall describe but one of these, that of Simon. 

Among other attempted improvements, Dr. Stavtin and M. Matthieu 
of Paris have invented hollow needles, through which the silver threads 
can be passed without first passing those of silk. Extended experience 
with tubular needles leads us to the conviction that they are at once 
the most ingenious and worthless appliances which can be employed. 

Simon s Operation. — No one, witli the exception of Marion Sims. 
has labored more earnestly or achieved more for this operation than 




262 FISTULjE of the female genital organs. 

Prof. Gustav Simon of Heidelberg. For this reason, and in order to 

aid in perpetuating his memory, we re- 
Fig. 127. produce his method at some length, 

although it is not employed in this 
country. The illustrations, which we 
reproduce from the original work, are 
among the best representations in exist- 

skene's Modification of Goodman's ence of the different varieties of vesico- 

Self-retaimng Catheter. , n , , , J , . 

vaginal fistula and tneir operative cure. 
Succeeding Dieffenbach, Wutzer, and Metzler, who had themselves 
accomplished a great deal in advancing the interests of the operation 
by suture, he steadily labored with the means at his command, and 
even before he became acquainted with the improvements made by 
Sims had acquired a great degree of skill in treating vesico-vaginal 
fistulse. To regard him as an imitator would be unjust. He was 
without question a coincident discoverer. 

The chief features of Simon's operation are these : 

1st. He repudiates silver wire as a suture superior to fine silk ; 

2d. He employs an exaggerated lithotomy position in place of the 
left lateral position ; 

3d. Instead of avoiding the- mucous membrane of the bladder, he 
intentionally involves it in his abrasion ; 

4th. He uses no stationary catheter, and has the urine drawn only 
during the first twenty-four hours, and this not always. 

5th. He allows the bowels to be evacuated whenever nature prompts 
it, and does not diet the patient nor confine her to bed. At times he 
even permits outdoor exercise in twenty-four hours after the operation 
in favorable cases. 

We prefer to describe his procedure as far as possible in his own 
words. The following resume of his method is made up from his 
work, The Operation for Vesico -Vaginal Fistula, published in 
1862: 

" Position of Patient. — There are three positions in general use for 
the patient in operation for vesico-vaginal fistula : (1) The back, as in 
operation for stone ; (2) the knee-elbow ; and (3) Sims's position, 
which is a modification of the latter. I use neither of these, but pre- 
fer the breech-back position (Steiss-ruckenlage), which has all the 
advantages of those mentioned without their disadvantages. It con- 
sists in this, that the patient, lying on her back, is put in a position 
which is almost exactly similar to the knee-elbow position. The 
breech is so elevated that it is somewhat above the level of the abdomen 
and breast. The thighs are bent back toward the belly and the sides 
of the chest, so that the breech is the most projecting part. The legs 
are either flexed at the knee or extended over the sides of the chest. 
The vulva is above and to the front. The head is supported by a pil- 
low. If the fistula is seated very high in the vagina, the thigh must 
be drawn as far as possible upward ; if the fistula is, however, very 
near the vaginal outlet, we are not obliged to elevate the breech so 
much, and have no need, therefore, of flexing the thigh so forcibly. 
I have called this, in distinction to the ordinary back position, the 



URINA R Y FIST TJLJE— TR EA TMENT. 



263 



4 Steiss-riickenlage,' 1 because in it the breech (Steiss) is the most pro- 
jecting part, and presents itself in a manner very similar to the breech 
presentation of the foetus. 

"The advantages are : 

"1st. The field of operation is clear; we are not obliged to ope- 
rate between the thighs ; 

Fig. 128. 




Simon's Position for Vesico-vaginal Fistula (Simon). 

" 2d. The assistance can all be given from the side, without hin- 
dering the operator; 

" 3d. It allows the use of several specula and the side retractors to 
expand the vagina on every side ; 

"4th. It is quite as well borne as the ordinary back position ; 

" 5th. It admits of chloroform narcosis 

"If the fistula can be brought down entirely with perfect ease, I 
bring it directly to light. If, however, there is the least difficulty in 
moving it (as in the majority of cases), I operate with the specula and 
retractors, with the fistula in situ. I always prove this by seizing the 
uterus with a hooked-forceps (Museux) and pulling it gently down 
before I operate with the specula and levers. I have improved Jobert's 
method of seizing the cervix with the forceps by passing two threads 
through the cervix, thus getting rid of an instrument which is very 
much in the way. Sims constructed a gutter-shaped speculum for 
expanding the fistula, which has left all other specula in the back- 
ground. He used four sizes. It is shaped like Neugebauer's (1856), 
except that instead of ending in a sharp edge it is rounded out at the 

1 Gluteo-dorsal position. 



264 



FISTULJE OF THE FEMALE GENITAL ORGANS. 



end. I have found the use of this speculum in many difficult cases 
absolutely insufficient, and in the majority of cases it only answers the 
purpose by the aid of other instruments to expand the vagina. I use, 
therefore, not this speculum alone, but also a flat-shaped speculum to 
hold up the other vaginal wall, and also side levers (shaped like retract- 
ors) to hold back the labia and sides of the vagina. All these instru- 
ments are fixed in long handles, curved at the end, in order to get 
them out of the way and to give the assistant a firm grasp. 

Fig. 129. 




Vivifying the Edges of the Fistula (Simon). 

" Always use the widest specula possible ; Sims's are not wide 
enough. I have had two sizes more made. 

"In addition to these I often use long-handled hooks to seize the 
edges of the fistula. I always cut the cord-like contractions of the 
vagina, and have even cut the vaginal folds which were in the 
way. 

Vivifying the Edges. — "All operators have tried to give a large 



URINARY FISTULA— VIVIFYING THE EDGES. 



265 



surface for union without enlarging the wound. They have done this 
by cutting at the expense of the vagina, leaving the edges of the blad- 
der intact. According to my observations and experience, I give the 
preference to a deep, funnel-shaped incision of the edges of the fistula, 
similar to the incision in plastic operations in any other part of the 
body. The incision must be carried to the healthy tissue and all the 
cicatricial tissue extirpated. 

" It extends quite through the walls of the septum to the vesical 
mucous membrane, and sometimes through it. 

" In this way is formed a steep, funnel-shaped wound, with its point 

Fig. 130. 




Incising the Edges of the Fistula, Mediate Access (Simon) 



in the bladder and its base in the vagina, and its edges from 6 to 8 mm. 
thick. 

"Although other authors wish to avoid as much as possible the 
enlarging of this defect, it is exactly here only, where union can rake 
place by first intention, that I strive to have the edges as tree from 



266 FISTULjE of the female genital organs. 

cicatricial substance and as prone to union as possible ; and even in 
the largest fistula I do not refrain from this repeated paring of the 
edges, even to making the defect very much larger, until the union is 
accomplished. And even if with the best preparation of the edges the 
union does not take place, and we meet with entire want of success, the 
woman loses no more urine than before. 

" Sometimes I cut the vesical mucous membrane, and sometimes 
avoid it, but place little weight on that. 

" The advantages claimed are — 

" 1st. By the deep funnel-shaped incision all cicatricial substance 
will be certainly cleared away. 

" 2d. The edges are more prone to union, as they unite in a nat- 
ural manner, edge to edge, and not with a flat surface on the same ; 
the nerves, vessels, etc. thus continue on in the normal direction. 

"3d. The very wide edge is unnecessary, as only the upper edges 
unite in any case. 

" 4th. If union does not take place the first time, a second attempt 
is more likely to succeed with the thick edges than where, with already 
thin edges, these must be bevelled off still more and made thinner. 

" 5th. The idea that catarrh is more likely to follow this form of 
incision is unfounded." 



Uniting the Edges of the Wound. 

Method of Uniting. — " There have been a great number of meth- 
ods of bringing the edges together ; all of which accomplish their 
purpose, but are more complicated than the method I published in 
1854, which, with some modification, I have used ever since. 

" In order to meet the indication for uniting, I use either one or 
two rows of fine silk sutures tied in the ordinary manner. 

" In large fistulas, where a great degree of relaxation is necessary in 
order to bring the edges into exact union, I use my so-called double 
suture, consisting of two rows, one the 'relaxing,' the other the 'unit- 
ing.' In small or in slit-shaped fistulas I use only one, the uniting row. 
In the double suture one row, placed very deep and wide, approaches 
the tissues surrounding the fistula to the line of union, thus relaxing 
the edges ; while the other, placed between the stitches of the first, 
holds firmly the edges, and thus promotes the most exact union. When 
only one is used, it is the uniting row, and placed in the same manner 
as here described. Of course each row of sutures supplements the 
other in its action. 

"Both rows are placed very deep, even, in many cases, through the 
vesical mucous membrane. They thus bring the edges of the wound 
in their whole thickness in the closest union, and withstand greater 
traction than if they only seized a part of the edges. The sutures are 
1-1J lines apart. The point of entrance of the threads is, in the 
relaxing suture, some distance from the edge — in the uniting, quite near. 
I consider it of very little importance whether the suture goes through 
the vesical mucous membrane or not. It is only necessary to be care- 
ful that this membrane does not get between the edges of the wound. 



URINARY FISTULA— AETER-TREA TMENT. 



267 



After- Treatment. — "1st. From a series of observations I conclude 
that neither on the wound nor on the new cicatrix does the urine have 
any injurious influence, and neither hinders the union by primary inten- 
tion nor loosens a once-formed cicatrix. 

" 2d. From another series of observations I have learned that the 

Fig. 131. 




Sutures Tied (Simon). 

healing is not interfered with by a degree of distension which could 
come in a normal filling of the bladder, provided only that the wound 
is perfectly freshened and united. 

" In most cases the permanent retention of the catheter only does 
harm. 

" Each of these deductions is drawn from a number of appropriate 
cases. 

" Upon these conclusions, then, is based my after-treatment, which 
up to the removal of the stitches is entirely unimportant. Those minute 
directions, the carrying out of which is so tedious both for the patient 
and physician, are all laid aside. The patient is permitted to take any 
position she chooses. She passes her water as soon as she feels the 
need, either in a bed-pan or, if she object to that, in the sitting or knee- 
elbow position. Only in a few cases, where the patient is not in a con- 
dition to pass water spontaneously, is the catheter used every three or 
four hours. On the fourth or fifth day an attempt is made to remove 
the stitches, and this is repeated on the following days. On the eighth 
day the patient is allowed to leave her bed, even if all the stitches are 
not out. 

"■To avoid passages from the bowels, with straining, on the first eight 



268 FISTULJS OF THE FEMALE GENITAL ORGANS. 

days, a fluid discharge is recommended. If irritation of the bladder 
ensue, morphine, one-eighth grain per dose, should be given, and daily 
warm injections into the vagina, but not into the bladder, should be 
employed." 1 

Prof. Simon 2 reports the following results: "Of 118 fistulae occur- 
ring in 105 patients, there were 104 fistulae in 92 patients cured com- 
pletely (a later cure is counted in under the first category) ; 5 fistulae in 
5 patients almost entirely closed ; 2 patients with 3 fistulae discharged 
as incurable; 6 patients died." 

In the description of Simon's method here given the words of the 
author have been employed as much as possible, and now, in conclud- 
ing our account of it, we proceed to express our opinion as to its value 
as compared with that of Sims. In a very few rare cases of extensive 
destruction of the base of the bladder in women who are exceedingly 
obese it answers a better purpose than that of Sims ; but as a rule it 
is difficult to appreciate how any one who has tried both can consider 
the former as comparable to the latter. Indeed, it may justly be said 
that Sims's method leaves so little to be desired that all others are com- 
pletely overshadowed by it. 

Elytroplasty. — This operation was published to the profession by 
Jobert de Lamballe 3 in 1834, and was subsequently altered and 
improved by Velpeau, Gerdy, and Leroy d'Etiolles. It consists in 
dissecting a flap from one buttock (Jobert), or the posterior wall of the 
vagina (Velpeau and Leroy), and fixing it by sutures into the orifice 
of the fistula, the borders of which have been previously pared. It 
resembles the operations of rhinoplasty performed upon the face, but 
is unfortunately even more difficult than they, and calls for such great 
manual dexterity as to preclude its frequent adoption. 

Elytroplasty may still be employed sometimes where great destruc- 
tion of tissue has taken place at the base of the bladder, but the dif- 
ficulties and uncertainties attending it, together with the fact that more 
simple and efficient methods for dealing with this class of cases are at 
command, have rendered a resort to it very rare. 

To one unaccustomed to the treatment of fistulae it would appear 
that the larger the fistula the more difficult would be its cure. This is 
not so : some of the most difficult cases will be found to be those in 
which the opening is so small as to be discerned with difficulty. In 
these cases we would strongly recommend the following plan : Intro- 
duce into the bladder a large steel sound, and by its extremity make the 
fistula to project toward the vagina; then cut away the tissue surround- 
ing the fistula, so as to let the so and pass freely into the vagina. 
Sutures may then be passed and the enlarged fistula cured. 

Closure of the Vagina (Kolpokleisis). 

This procedure is resorted to in despair of accomplishing the cure of 
the fistula, and in the hope of relieving the patient from the intolerable 

1 This resume has been prepared from Prof. Simon's work by Dr. M. D. Mann. 

2 Am. Journ. Obstet., vol. ii. p. 241. 

3 Bull, de VAcad. de Med. de Paris, t. ii. p 145. 



URINARY FISTULA -CLOSURE OF THE VAGINA. 



269 



annoyance attendant upon an involuntary and constant discharge of 
urine. It does not, of course, equal in efficiency closure of the vesical 
fistula, since it involves the necessity of the urine being retained in the 
vaginal canal, which is injured by its presence, and is proposed only for 
those cases in which, from extensive destruction of tissue, no hope of 
closure by suture or elytroplasty can be entertained. By it the vagina 
and bladder are rendered a common receptacle for urine and menstrual 
blood, the only advantage gained consisting in the fact that they may be 
retained and discharged at will through the urethra, which remains open. 
Closure of the vagina may be accomplished by two operations — 
episiorrhaphy and obliteration of the canal. The first, which consists 
in paring the inner surfaces of the labia majora and uniting them by 
sutures so as to cause their complete adhesion, originated with Vidal de 

Fig. 132. 




Obliteration of the Vagina (Simon). 



Cassis, who performed it in 1838. The operation is exceedingly simple 
in its steps, but a very minute opening almost invariably remains just 
under the meatus, through which a little urine exudes. This vow nearly 
invalidates the success of the method, for even a slight escape renders 
the patient uncomfortable. 



270 FISTULJE OF THE FEMALE GENITAL ORGANS. 

The second consists in paring, not the labia, but the vaginal walls. 
Strips of mucous membrane being thus taken away, the bleeding sur- 
faces are brought in contact by suture, and the bladder is kept empty 
by a catheter until union has occurred. This procedure, a far more 
valuable and reliable one than that of Vidal, was first performed by 
Simon, who has applied to it the name of " kolpokleisis," or cross 
obliteration. Prof. Simon's first operation was performed in 1855, and 
since that time he declares that it has been resorted to in Germany in 
over fifty cases with complete success, and many cases suffering from 
incontinence of urine due to great loss at the base of the bladder have 
been entirely relieved by it. He places a very high estimate upon the 
operation, as the following extract from a published letter from him to 
Dr. Bozeman of this city will show : 

" The reason why I have proved the validity of my claims of priority at 
such lengths is simply this, that in my opinion kolpokleisis is the most 
important plastic operation which in the last clecennia has originated from one 
single man. The operation of vesico-vaginal fistula by uniting the borders 
of the defect is indeed, in its present perfection and precision, a much more 
important acquisition than kolpokleisis, and probably the greatest achieve- 
ment of our century in plastic surgery ; but it has not been carried to that 
perfection by a single man, but, on the contrary, operators of all nations 
have contributed their share to it. The ' uranoplastie ' of our ingenious 
countryman, Yon Langenbeck, could alone be placed by the side of kolpo- 
kleisis, as far as the safety of the performance and its immediate success 
are concerned. It would rank higher still on account of its more frequent 
occurrence if its benefit for the voice in increasing its purity could be 
secured in all or the majority of cases. But as in many cases this result is 
not obtained at all, and in others only incompletely, kolpokleisis must be 
considered the more important operation, as in all cases it fully answers 
its purpose. This operation, which I invented at the time when the obliter- 
ation of the vulva, proposed by Vidal, proved inefficacious in re-establishing 
continence of urine, has already been performed more than fifty times with 
complete success. Through it many patients with incurable defects of the 
bladder have been freed of the most intolerable suffering — viz. incontinence 
of urine. I have myself succeeded in eighteen cases in effecting perfect 
obliteration, and every German surgeon who practises the art of curing 
vesico-vaginal fistulas has recorded one or more successful cases of that 
kind." 

In his earlier operations Prof. Simon confined this procedure to the 
lower section of the vagina, but he now r obliterates the canal just 
below the loss of substance. 

A recent German operator has recommended and successfully prac- 
tised an operation by which the accumulation of menstrual blood and 
urine is transferred from the bladder to the more tolerant rectum. He 
first makes a recto-vaginal fistula, and when this is healed closes the vagi- 
nal cleft from posterior commissure to clitoris. In time the rectum 
becomes able to retain the urine as long as three hours, or a much 
longer time than the usually contracted bladder in such cases will ever 
attain. 



VESICO- UTEB 0- VA GIN A L FISTULJE. 



271 



Urinary Fistulee requiring Special Treatment. 

In the great majority of instances no other plan of treatment than 
the suture is necessary. There are, however, 
cases of urinary fistulas in which the application Fig. 133. 

of the suture is difficult or even impossible. 
These will now engage our attention. 



T r esieo-cervical Fistulce. 

Jobert first pointed out the proper method 
for reaching these. His plan is not at present 
employed, but that now regarded as most reli- 
able is only a modification of it. It consists in 
slitting up the anterior lip of the uterus until the 
fistula is reached, vivifying its edges, and pass- 
ing sutures directly through the cervix, as rep- 
resented in Fig. 133, so as to approximate the 
walls of the cervix and the lips of the fistula. 

In case the fistulous orifice be so high as to 
be considered beyond reach, the only remaining 
resource is to close the os uteri externum by 
suture and allow menstruation to occur through the bladder 




The Cervix is slit to Expose 
the Fistulse above, and 
Sutures are passed. 



Vesico-utero-vaginal Fistulce. 

For these the plan of vivifying the anterior lip of the os, and thus 
making the uterine tissue subservient to closure of the fistula, is pecu- 




Anterior Lip of Fistula united to Anterior Lip of Cervix (Simon). 

liarly applicable. The operation, represented at Fig. 134, is similar 
to that for ordinary vesico-vaginal fistula, the only difference being 

that one lip of the fistula is made of the vivified cervix uteri. 



272 



FISTULA OF THE FEMALE GENITAL ORGANS. 



In case the anterior 



Fig. 135. 




of the uterine neck be so completely 
destroyed that it cannot fur- 
nish the requisite tissue for 
this purpose, the vagina may 
be united to the posterior lip 
so as to throw the cervix into 
the bladder. Menstruation 
will afterward occur into that 
viscus, and the blood thus 
accumulating be discharged 
with the urine. 

Fistulas with Extensive De- 
struction of the Base of 
the Bladder^ 

It has already been men- 
tioned that elytroplasty and 
kolpokleisis offer resources 
in these cases. To Dr. Boze- 
man, however, we are in- 
debted for still another pro- 
cedure, the first step of which 
consists in dragging the ute- 
rus down daily for weeks be- 
fore the operation by means 
of a pair of forceps, by which the neck is seized. In this way the uterus 
is made to approximate the vulva. Then one lip of the cervix, being 
vivified, is brought into contact with the extremity of the remains of 
the vesico-vaginal septum and firmly united with it by suture. 

To facilitate this procedure the cervix may with great advantage be 
slit to the vaginal junction, drawn forward, and made to fill the space 
left vacant by the sloughing of the vagina. 

We would call attention to one danger from this procedure — namely, 
the rupture of unknown adhesions between the uterus and adjacent 
organs, which may cause severe or fatal peritonitis. We have known 
such an accident to occur. 

Uretero-uterine and Uretero-vaginal Fistulee. 

In addition to the varieties of urinary fistulge mentioned here, cer- 
tain rare instances of union between the ureters and vagina or uterus 
have been recorded. A striking example of uretero-uterine fistula may 
be found detailed in the Dictionnaire de Medecine, vol. xxx., by M. 
Berard. It is not only interesting in itself, but, as displaying the 
method by which the diagnosis may be arrived at, is worthy of special 
mention. Regarding it at first as a vesico-uterine fistula, from the 
fact that urine was discharged from the uterus, he arrived at a different 
diagnosis from these facts : 

1st. The urine flowed steadily from the cervix when the bladder 
was empty. 



Vesicouterovaginal Fistula, Sutures in place (Simon). 



URETERO-UTERINE AND URETERO-VAGINAL FISTULA. 273 

2d. The urine thus flowing was limpid, unlike that from the bladder. 

3d. The patient being kept seated over a vessel for two hours, so as 

preserve all the urine flowing per vaginam, a catheter was passed into 

Fig. 136. 




Posterior Lip united to Anterior Edge of Fistula (Simon). 

the bladder and the amount removed exactly equalled that which had 
escaped vicariously. 

4th. Injecting the bladder with fluid colored by indigo, the urine 
passing per vaginam remained limpid. 

5th. A sound being passed into the uterus and another into the 
bladder, their points could not be brought into contact. 

Uretero-uterine fistula is by no means common ; only one instance is 
mentioned by Dr. Emmet in his well-known work as having occurred in 
his extensive experience. Dr. W. H. Baker 1 of Boston has recently 
published an interesting case, which was cured by dissecting up the 
ureter, which ended at a point near the meatus urinarius, making an 
opening near the neck of the bladder, turning the ureter into this, and 
then closing the vaginal wound. 

Dr. Henry F. Campbell 2 of Georgia reports an interesting case of 
uretero-vaginal fistula which he cured by this simple procedure : Passing 
a small bistoury up the ureter, he slit its anterior wall, the knife pass- 
ing into the bladder. He then closed the vaginal surface of the cut thus 
made with silver suture. The patient rapidly and entirely recovered. 

l N. Y. Med. Journal, Dec, 1878. *Amer, Joum., Med. Sciences, Jan., L880. 

18 



274 FECAL FISTULJE. 

An exceedingly interesting instance of this variety of fistula is men- 
tioned by Zweifel of Erlangen, in which he removed the kidney of the 
diseased side with a successful result. The right kidney, which was 
left, proved quite sufficient for the wants of the economy. 

There are eccentric and rare forms of fistula which we have not men- 
tioned in my enumeration. For example, we have met w T ith three cases 
of vesico-abdominal fistula. In one of the cases eight days after the 
operation of ovariotomy about one pint of urine began to pass daily 
through the abdominal opening, the lower angle of which had been 
kept open for washing out the peritoneum. That the fistula was vesi- 
cal, and not ureteral, was proved by the escape of colored fluid through 
the abdominal wound when injected into the bladder. This patient 
entirely recovered and the fistula healed of itself. 

Where a larger extent of denudec 1 surface is required than can be 
obtained by paring the edges of fistulae, Langenbeck and Colles have 
resorted to the following plan : Splitting the edges of the fistula, they 
have separated the two flaps thus produced, and, bringing the opposing 
raw surfaces together, have secured them by suture. This method has 
recently been revived by Tait, who operates by touch only. But he 
has so far found no imitators on this side of the Atlantic. 

Treatment of Long, Tortuous, Capillary Sinuses remaining after Opera- 
tion by Suture. — [Sometimes fistulae situated near and involving the neck of 
the uterus will be cured in great part by suture, and yet at one or both 
extremities of the original opening long capillary sinuses will remain, which, 
running a tortuous course, reach the bladder and render the operation a fail- 
ure. Under these circumstances it is almost impossible to pare the edges 
of these tracts by knife or scissors, and the cautery, which has been generally 
used for them, commonly fails to cure them. For these I have adopted with 
the most satisfactory results the following plan : Having a dentist's burr 
made with cutting flanges, instead of dull ones, such as are usually employed, 
it is fitted to the ordinary dentist's treadle ; as the burr is made to revolve 
rapidly by the action of an assistant's foot, it is passed several times up 
and down the sinus to be closed, until the operator feels that the entire canal 
is thoroughly denuded. Then by curved needles deep sutures are passed, 
approximating its vivified walls. By this means I have cured several fistulae 
situated just in contact with the cervix uteri, which would been exceedingly 
difficult of cure by any other method. It has the advantage of being very 
expeditious, and I would urge its claims in this class of cases. — T. G. T.] 



CHAPTER XVIII. 
FECAL FISTULA. 



Definition. — These, which are much less frequently met with than 
urinary fistulae, consist in communications established between the 
vagina or vulva and some part of the intestinal tract. 

Varieties. — They may be recto-vaginal, entero-vaginal, or recto- 



RECTO-VAGINAL FISTULA. 275 

labial ; the first being the most common, and the second the rarest 
of the varieties. 

Causes. — The causes which produce them are almost identical 
those which result in urinary fistkfee — y\?,. 
Prolonged pressure; 
Direct injury ; 
Ulceration or abscess. 

The first of these may produce tl 
the anterior vaginal wall, by ere 
results in sloughing, or the inteiisitj 
as rapidly to destroy the vitality of 
frequently the result of difficult part 
arise from badly-fitting pessarie, or 

Direct injury by instrument^ use 
for removal of impacted feces n 

Ulceration or abscess much mo* 
urinary fistula. For the recto-vir ;ino 
fruitful source, the stricture proc 
excites ulceration that may extend 
between the vagina and rectum nay i 
two, or, burrowing toward one j bi.ui 
part by a tract with the rectun It 
lection has, been known to mal a \ 
vagina. Lastly, syphilitic anc nc 
nel between the intestinal anc vag 

Symptoms. — The most prominen 
will attract the patient's atten on \ 
or fecal matter by the vagim Ti 
course be governed by the size o 
dependent upon the accident will not 
tity will be sufficient to rend( ■ th( 
offensive odor to which it give rise. 

Physical Signs. — The patie t being upon fch< 

should be practised upon all the surface f the vagina. 
be one of any magnitude, this wi 

exploration by the speculum will alniusi aiwajo do »-v. Sims s speculum 
should be introduced under the symphysis, so as to lift the anterior 
wall of the vagina while the lateral walls are held aside by spatulre. 
Should visual exploration not reveal the opening, the rectum may be 
filled with tepid water colored with cochineal or indigo, and its escape 
carefully watched for, or the recto-vaginal septum may be lifted up with 
the index finger in the rectum, and the fistula be thus exposed. 

Prognosis. — Fecal fistulae are more likely to be spontaneously 
recovered from than those of urinary character, from the fact that 
they give passage to occasional gaseous and semifluid excretions, and 
not to a fluid which is constantly dribbling away and keeping the fis- 
tulous walls from uniting. But even these are rarely recovered from 
unless surgical aid be brought to their relief. 

Treatment. — Recto-vaginal and recto-labial fistuhv should always 
be treated by denudation and suture. 



276 FECAL FISTULJE. 

This is practised upon the same plan as that which is followed in 
vesico-vaginal fistulse, with these exceptions, that the patient is placed 
in the position adopted in operating for stone, and that the speculum 

is so inserted as to elevate the ante- 
rior instead of the posterior vaginal 
wall. Before operation the sphincter 
ani muscle should always be par- 
alvzed bv thorough stretching by 
the fingers, and after it a rectal tube 
should be retained, unless very an- 
noying to the patient. After the 
operation, too, the rectum, which 
should have been thoroughly emp- 
tied by enema before it, should be 
kept perfectly quiet by opiates for 
ten or twelve days. When evacua- 
tions are first permitted laxatives 
mould be employed in order to avoid 
enesmus, which might destroy the 
mion of the lips of the fistula. 

In one case of recto-vaginal fis- 
ula we have introduced the spec- 
Jum into the rectum and closed the 
istula on the rectal surface. The 
facility with which the operation was 
>erformed was surprising. Should 
he fistula exist only a short dis- 
ance above the sphincter ani, the best 
brm of treatment is to cut com- 
)letely through the perineal body, 
vivify carefully, and close the 
wound, precisely as in the opera- 
tion for complete laceration of the perineum. 

Enter o- vaginal Fistulae. 

Entero-vaginal Fistula, which consists in a fistulous tract between 
some part of the intestinal canal above the rectum and the vagina, is 
rare, and when existing should be looked upon as an artificial anus, the 
closure of which would be attended by danger. If the opening be 
direct and there be no tract leading from one canal to the other, this 
would not be the case, but if a tract exist the closure of its vaginal 
extremity would probably result in abscess excited by fecal matters 
passing out of the intestine. 

Simple Vaginal Fistulee. 

Definition. — Under this head are grouped those forms of fistulous 
connection with the vagina which do not act as vicarious outlets for any 
neighboring organ, as, for example, peritoneo-vaginal, perineo-vaginal, 
blind fistulae. 



ACUTE ENDOMETRITIS. 277 

Peritoneo-vaginal Fistula has been rarely met with. When it 
does occur it is attended by danger of descent of the intestine into the 
vagina and entrance of fluids and air into the peritoneal cavity. One 
reason for its rarity is probably the fact that, no excrementitious sub- 
stance passing through it, it very generally disappears without becoming 
chronic. Should it not do so, no annoyance would arise from its exist- 
ence, and it would be susceptible of immediate cure by suture. 

Perineo-vaginal Fistula may result from partial closure of a rup- 
tured perineum, leaving a small orifice near the sphincter ani; from 
penetration of the presenting part of the foetus through the perineum ; 
or from paravaginal or pararectal abscesses which have burrowed toward 
the skin and opened on the perineum. It may be readily cured by 
incision, ligature, cauterization, or injection, after the plan just pointed 
out in connection with fecal fistulae. Thorough incision, with use of 
the sharp curette and packing with iodoform gauze, forms the most 
reliable treatment. 

Blind Vaginal Fistula? are those which lead to a purulent collection 
in some part of the pelvis. They will be fully treated of when con- 
sidering pelvic abscesses, and nothing need be said of them here further 
than to mention the principles upon which their treatment rests : 1st, 
dilatation of the fistulous tract by tents or incision ; 2d, exerting an 
alterative action on the walls of the abscess by the sharp curette and by 
iodine, iron, nitrate of silver, etc. 



CHAPTER XIX. 
ACUTE ENDOMETRITIS. 

We freely confess that the arrangement of no subject treated of in 
this work has caused us more perplexity, and is offered to the reader 
with greater hesitancy, than that which relates to the division of endo- 
metritis. Having personally no theory to sustain in reference to the 
matter, our sole desire is to present the subject in the manner which 
will best aid in its comprehension, assist the practitioner at the bedside, 
and favor a future, advance in its pathology. 

Throughout the literature of gynecology admissions will everywhere 
be found of the fact that endometric inflammation limits itself to the 
neck, the body, or even, according to one authority, 1 to the fundus of 
the uterus, and yet the two varieties of the affection are treated of as 
one, and one author 2 even goes so far as to assert that " the facility for 
locating its limit exclusively to cervix, body, or fundus rests only in 
the brain of the theorist." Barnes treats of the whole subject as 
"endometritis," yet with characteristic candor he says, "It appears to 
me that attention has been too strictly fixed upon the visible changes in 

1 Dr. Eolith's article on "Fundamental Endometritis." 

2 Dr. T. A. Emmet, op. tit. 



278 ACUTE ENDOMETRITIS. 

the cervix and os uteri, and that, thus engrossed, the mind has been 
closed against the less telling evidence of changes in the body of the 
uterus." 

All things being carefully considered, we have thought it best to 
adhere to the arrangement which follows, guarding the reader against 
the idea that any facility of differentiation, any dogmatic certainty of 
conclusion, is claimed in reference to the matter. The arrangement 
simply seems to us, for many reasons, that which best meets the 
requirements of the present and favors the prospects of the pathology 
of the future. 

The varieties of inflammation of the lining membrane of the uterus 
may be clearly expressed in the following manner : 

f General, 
Acute, < Cervical, 



Endometritis. 



( Corporeal. 



( General, 
Chronic, < Cervical, 
( Corporeal. 

While we think that a catarrhal inflammation of the neck of the 
uterus may very well exist without involvement of the body of the 
organ, we feel convinced that the cervix can scarcely escape if the 
upper portion of the uterus is diseased. 

Synonyms. — Acute endometritis has been treated of under the names 
of acute uterine leucorrhcea, acute uterine catarrh, acute internal metritis. 

Frequency. — Acute inflammation of the lining membrane of the ute- 
rus is a condition which occurs quite frequently. Often running a rapid 
course, however, and ending in recovery or in chronic disease, it passes 
unrecognized in many cases. In this way we would explain many of 
the cases of suppressio mensium and congestive dysmenorrhea which 
we so often find ending in chronic disease. And thus also would Ave 
account for the profuse and painful attacks of leucorrhcea occurring 
with exanthematous fevers, and lasting for a length of time after they 
have passed off. It is very generally stated that acute metritis is sel- 
dom met with except as a sequel of parturition, and we agree in the 
statement as applying to parenchymatous inflammation ; but it does not 
apply to endometritis, which often proves the source of sudden menstrual 
disorder and the cause of violent leucorrhcea. 

Varieties. — The morbid process may affect the lining membrane of 
the cervix or of the body alone, or it may attack the whole uterine 
mucous tract, its selection of site being governed by its cause. Thus, 
that form which immediately follows parturition or abortion (the so-called 
"endometritis of subinvolution") or results from gonorrhoea is likely 
either to affect the whole mucous tract or the cervical canal alone ; 
while that which is due to sudden checking of the menstrual flow is 
more likely to be confined to the body. 

"While, theoretically, a sharp limitation of the catarrhal condition 



CA USES. 279 

may readily be made between the cavities of the body and the cervix 
uteri, so close a line cannot usually be drawn in practice. A catarrhal 
inflammation of the body of the uterus will usually spread to, and by 
direct contact infect, the mucous lining of the cervical cavity. But tbe 
converse does not hold good in nearly the same proportion. A cervical 
endometritis dependent on laceration of the cervix, for instance, very 
commonly is limited to that part only, the mucous membrane of the 
body of the uterus remaining perfectly healthy. 

Causes. — The causes of acute endometritis are the following : 
Direct injury ; 

Cold from exposure during menstruation ; 
Constitutional disease of septic or asthenic character ; 
General ansemia ; 
Vaginitis, specific or simple ; 
Excessive venery ; 
Suppression of menstruation. 

Examples of direct injuries which may produce acute endometritis 
are the introduction of the uterine sound or the intra-uterine pessary, 
the employment of tents or the application of chemical irritants, sur- 
gical operations, and intemperate coitus. 

It is probably in some instances through the instrumentality of this 
disease that those cases of fatal peritonitis which result from tents, 
sounds, and intra-uterine pessaries occur. Inflammatory action is first 
set up in the lining membrane of the uterus, and thence swiftly passes 
through the Fallopian tubes to the peritoneum. 

Specific vaginitis or gonorrhoea will sometimes pass up into the cer- 
vix and body of the uterus and out through the Fallopian tubes, creat- 
ing pelvic peritonitis of most violent character. Even simple vaginitis, 
when of very severe form, may produce endometritis, though this is by 
no means common. 

The peculiar blood-state attending upon and forming an element of 
measles, scarlatina, variola, and roseola, and exerting its influence on 
all the mucous linings of the body, will sometimes result in general 
endometritis and general anaemia, and the hemic condition resulting 
from phthisis very frequently does so. 

Exposure to cold and moisture, great mental anxiety, or any other 
influence which suddenly checks the menstrual flow not infrequently 
produces this disease. At the moment of exposure suppressio mensium 
or congestive dysmenorrhoea may take place, and from that time endo- 
metritis may exist. When we consider that such a sudden check of 
menstruation will sometimes result in hematocele of fatal character, it 
is certainly not to be wondered at that it may likewise produce the dis- 
ease of which we are speaking. 

Excessive venery, even where no violence is done to the uterus, may 
produce it by the prolongation of intense congestion of the organ kept 
up by this act. 

Frequency. — Although we do not deny that the acute stage o\' this 
disease may occur frequently, we still have had but tew opportunities of 
seeing it uncomplicated witli pelvic peritonitis or cellulitis. Generally, 
when the cases of endometritis came to our notice thev had become 



280 ACUTE ENDOMETRITIS. 

subacute or chronic, or the disease of the endometrium was secondary 
to inflammation of the uterine adnexa or the pelvic peritoneum. 

Symptoms. — The disease demonstrates its presence in the non-puer- 
peral uterus without any very violent symptoms. 

Ordinarily, the patient complains of pain, weight, and dragging in 
the pelvis ; pain in the back, groins, and thighs ; burning and prick- 
ing in the vagina ; and vesical and rectal tenesmus. After four or five 
days there is usually a discharge of a viscid liquid, which in eight or 
ten days becomes creamy, purulent, and perhaps bloody ; tympanites 
and sensitiveness upon pressure and uterine tenesmus or " bearing-down 
pains" show themselves in severe cases, and at times, though rarely, 
there is active diarrhoea, due to reflex irritation of the rectal nerves. 
Should the fluid discharged from the vagina be allowed to come in con- 
tact with the skin of the vulva, abdomen, or thighs, an intense cuta- 
neous irritation is established, which may go on to excoriation and the 
development of pruritus of aggravated character. In two cases we 
have seen prurigo thus excited which spread over the entire body. If 
the reaction of this purulent discharge be examined into, it will some- 
times be found to be acid and at other times alkaline. The explana- 
tion of the fact is this : the discharge from the uterus is alkaline, and 
that from the vagina acid. If the irritating uterine fluid have estab- 
lished, as it very generally does, vaginitis, the acid secretion from this 
source overcomes the alkalinity of that from the other. If, on the 
other hand, no severe vaginitis exist, the discharge from the uterus 
presents its ordinary alkaline features. 

Physical Signs. — Upon examination by touch the os uteri is found 
gaping, the cervix swollen and very sensitive to pressure, the body 
slightly enlarged, and the whole organ lower than normal in the pelvis. 
Through the speculum the cervix is found to look swollen, oedematous, 
and red, and from the pouting os pours forth either a clear, albuminous- 
looking fluid muco-pus or long tenacious shreds of cervical mucus. All 
explorations of the uterus should, as a rule, be avoided. The probe, 
if used at all, should be employed with the greatest caution, and never 
unless passed through the speculum. The sound as ordinarily used 
should not be thought of. Probing will discover great sensitiveness 
throughout the uterine cavity, and the slightest touch upon the fundus 
will cause the discharge of a few drops of blood. Indeed, so great is 
the engorgement that even the introduction of the speculum will often 
cause blood to flow from the cervix. 

Bimanual examination will discover the uterine body enlarged and 
tender upon pressure, so that one who judged hastily and without 
sufficient knowledge of the subject would be very apt to diagnosticate 
with great positiveness acute parenchymatous metritis. There can be 
no doubt that many of the reported cases of that affection have been 
nothing more than instances of this form of endometritis. 

Differentiation. — The only diseases with which this would with any 
probability be confounded are para-uterine cellulitis, pelvic peritonitis, 
and acute vaginitis. In the first two of these constitutional disturb- 
ance is generally more marked and excessive than in this ; they are 
often preceded by chill, and usually by more intense febrile action and 



DIFFERENTIATION— COMPLICATIONS. 281 

greater elevation of temperature. This, however, is not universally 
true. The last is very generally attended by a lesser degree of 
general disturbance. No positive conclusion can usually be arrived at 
without physical exploration, which in pelvic inflammation will dis- 
cover fixation of the uterus, hardening of peri-uterine tissue, and 
excessive tenderness when parts other than the uterus are compressed 
by conjoined manipulation. It will be generally noticed that in cel- 
lulitis and peritonitis there is but a moderate increase of uterine or 
vaginal discharge. 

Pathology. — In its first stage acute endometritis consists in an 
intense and active hyperemia of the mucous lining of the uterus, 
which is red, swollen, cedematous, and softened. Its surface is spot- 
ted, Scanzoni declares, from congestion of the capillary network around 
the mouths of the utricular follicles. When the second stage has set in, 
the cavity of the uterus is found to contain an excess of mucus or 
creamy-looking pus, which may be more or less mingled with blood. 
If the cervix be involved in this inflammatory engorgement, the mucous 
membrane of its vaginal portion participates markedly, as an exami- 
nation by the speculum will prove. 

In the mucus just mentioned the microscope reveals the presence of 
thousands of cells, and sometimes entire casts of the utricular follicles. 

"Ordinarily," says Scanzoni, 1 "acute catarrh of the mucous mem- 
brane of the uterus is accompanied by a congestive swelling of the 
muscular substance of the womb, and most generally it is possible, 
particularly in the most internal layers of the organ, to see with the 
naked eye that the vessels are gorged with blood. There ordinarily 
result from it an infiltration and a softening, which are much greater 
in the layers of the parenchyma of the uterus nearest to the mucous 
membrane. Hence those alterations of tissue which are character- 
istic of acute parenchymatous metritis ordinarily accompany catarrh 
of the mucous membrane when this has attained a high degree of 
intensity." "The whole substance of the uterus," says Klob, 2 "gen- 
erally appears to be increased, and its tissue more vascular and succu- 
lent, especially in the layers nearest the mucous membrane." 

Acute endometritis very rarely shows itself before puberty. 

Complications. — Its complications are acute metritis, urethritis, 
vaginitis, vulvitis, cystitis, salpingitis, pelvic peritonitis, and various 
eruptive disorders the results of scratching excited by pruritus 
vulvae. 

The first of these complicating conditions is of so much moment as 
to require special consideration. 

The time has, we think, arrived when with our present light upon 
the subject acute parenchymatous metritis should be given a subordi- 
nate place in pathology, instead of the prominent one which it formerly 
occupied. With reference to its frequency as a primary affection many 
conflicting statements will be found. This arises partly from the fact 
that some have written of it without making any distinction between 
the forms occurring in the puerperal and non-puerperal states, while 

1 Disease* <>/ Females, American ed., p. 193. 

2 Path. Aunt. Female Sex. Organs, American ed., 231. 



282 ACUTE ENDOMETRITIS. 

others have confined their remarks, as it is here done, to the disease in 
the latter condition, partly from endometritis, active congestion from 
suppressio mensium, and peritonitis and cellulitis having been mistaken 
for metritis, and in great part from the difficulty of gaining post-mor- 
tem evidence, the disease being rarely fatal. As a complication of 
inflammation of the internal mucous or external serous covering of 
the uterus, parenchymatous inflammation is universally admitted. As 
a pathological entity, however, we question whether any well-authen- 
ticated case of this affection is on record. The descriptions of the dis- 
ease which are given in recent works — such, for example, as those of 
Courty. Gallard, and Scanzoni, each of whom devotes considerable 
space to it — appear to us to have come down to us as a matter of lit- 
erary tradition rather than of clinical research. 

"While searching for a case of pure uncomplicated metritis we have 
seen numbers of cases which were regarded by others as of this cha- 
racter, and quite a number which we viewed as such until enlightened 
by post-mortem or other evidence. Rokitansky 1 declares that "in 
acute inflammation of this organ generally the lining membrane of the 
uterus is affected primarily, and that this is scarcely ever the case with the 
uterine tissue, as far as can be demonstrated by the pathological anato- 
mist, with the exception of the reaction following traumatic influences, 
especially of the vaginal portion." 

Klob 2 takes still stronger ground as to the existence of uncomplicated 
metritis, and asserts that, never having met with an instance of the 
disease, he is forced to describe it upon the authority of others. 

Some practitioners are prone to regard every case of inflammatory 
action in the pelvis, accompanied by great tenderness over the uterus, 
as "metritis." Such cases are much more frequently due to pelvic cel- 
lulitis or peritonitis, which are by no means rare affections, or to active 
congestion caused by suppression of the menses or excessive coition. 
After parturition, either at term or premature, true metritis does occur 
not unfrequently. but this variety does not concern our present inves- 
tigation. As regards that form which we are considering, we feel 
convinced that, if the experienced practitioner will put aside his precon- 
ceived views and interrogate the results of his observation, he will find, 
if he has his attention aroused to the frequency of the diseases which 
simulate it. that he has met with this affection very rarely. 

Course, Duration, and Termination. — Acute endometritis, when 
occurring in the non-puerperal state, may. without treatment even, go 
on to recovery, generally lasting from a month to six weeks, and per- 
haps passing through its whole course without its existence having been 
diagnosticated. It sometimes ends in the chronic form of mucous 
inflammation, or even in slight hyperplasia, the superficial subjacent 
connective tissue becoming affected. It is doubtful whether any severe 
case of endometritis runs its course without being to a greater or less 
extent complicated by a slight degree of parenchymatous disorder. As 
already stated, the disease may end in chronic endometritis or in recov- 
ery. It may likewise end in death, inflammatory action spreading 
along the Fallopian tubes and causing salpingitis, which, by resulting 
1 Patholog. Anat. 2 Path. Anat. Female Sex. Organs, American ed.. p. 231. 



TREATMENT. 283 

in free purulent discharge into the peritoneum, may establish inflamma- 
tion there. 

Prognosis. — In spite of all these possibilities the prognosis is always 
favorable if the patient takes ordinary care of herself and yields to a 
judicious plan of treatment. But it should always be borne in mind 
that the apparent acute endometritis may be but the precursor or com- 
panion of an attack of acute pelvic peritonitis, and that the treatment 
should be directed toward the latter condition quite as much as toward 
the former. 

Treatment. — The diagnosis having been clearly made, treatment 
should be at once established. Complete rest of mind and body should 
be regarded as essential points. In severe cases the patient should be 
kept perfectly quiet upon her back in bed, and not allowed to leave it 
or to assume the sitting posture even to satisfy the calls of nature. 
Opium should be given by mouth or rectum for the production of per- 
fect nervous quiescence and for the relief of pain, the dose and the fre- 
quency of its repetition depending entirely on the severity of the pain. 
When the latter is relieved the opium should be discontinued. The 
bowels should be regulated by mild saline laxatives, and ordinarily no 
other medicine is required than antipyrine, phenacetine, or antifebrine, 
if the rise of temperature calls for them. Over the hypogastrium a soft, 
warm poultice of powdered linseed should be placed and covered by oiled 
silk. This need not be renewed oftener than once in twelve hours, for 
the oiled silk will preserve its warmth. Or if poultices cannot be pro- 
cured, hot fomentations will do very well, the cloths being covered with 
oiled silk and changed as often as they begin to dry. The patient should 
not be annoyed by leeches or cups. The diet should be very simple, and 
should consist of fluid food chiefly, as milk, beef-tea, etc. As soon as 
free secretion of muco-pus begins to show itself the vagina should be 
gently syringed out three times daily with copious injections of very 
warm water, administered from a fountain syringe, with the patient 
lying on a douche-pan or on a rubber sheet at the edge of the bed. 
All examination by speculum, probe, and, after a diagnosis has been 
made, even by the finger, should be avoided unless some special indi- 
cation demand it. Astringent injections and all vaginal applications 
are injurious. The affection which we are treating is located in the 
uterus, not in the vagina, and such applications merely annoy the 
patient and aggravate the disease. The warm injections which have 
been advised act as poultices or fomentations to the whole internal sur- 
face of the pelvis, at the same time that they ensure cleanliness to the 
vagina and remove from it a fluid which if left there might excite vag- 
initis. Under this plan of treatment the patient should be kept until 
recovery, or until we are admonished by time that the disease has passed 
into its chronic form and requires different remedies. 

More active measures, such as the application of leeches to the cer- 
vix or the introduction of the solid stick of nitrate of silver into the 
uterine canal for the purpose of cutting short the inflammatory process. 
should on no account be adopted. They are relics of now-abandoned 
therapeutics, and would be more likely to light up an acute pelvic peri- 
tonitis than to reduce the catarrhal inflammation for which thev arc used. 



284 CHRONIC CERVICAL ENDOMETRITIS. 



CHAPTER XX. 
CHROXIC CERVICAL ENDOMETRITIS. 

When inflammation of acute character affects the uterus, it has a 
marked tendency to invade the entire organ and to involve both cervix 
and bodv, but with chronic inflammation this is not the case. Being 
of a lower grade of intensity, it more strictly confines itself to the 
mucous membrane and limits itself to the body or cervix. Such limit- 
ation is, however, neither universal nor absolute, sometimes subjacent 
parts being more or less implicated, and at others the mucous membrane 
of the entire organ being simultaneously and equally involved. 

Definition. — By the term chronic cervical endometritis is meant 
chronic inflammation of the mucous membrane, extending from the 
os externum to the os internum. 

Frequency. — Of all diseases of the genital system of the female, 
this is without doubt the most frequent, and, although not in itself a 
malady of dangerous character, may prove the starting-point for some 
of the most serious and rebellious of uterine disorders. Exposed as 
the cervix uteri is to injury during coition, laceration from parturition, 
and irritation from walking, riding, and lifting, it is not surprising that 
its complicated investment should frequently become the seat of disease. 

This affection, too, is a frequent source of menstrual disorders, and 
very commonly produces sterility. 

Synonyms. — It has been described under the names of cervical 
catarrh, cervical leucorrhcea, and endocervicitis. 

Anatomy of the Cervical Mucous Membrane. — The cavity of the 
cervix uteri is a fusiform canal measuring about one inch and a quar- 
ter, beginning at the os externum below and ending at the os internum 
above. On the anterior and posterior walls of the cervix are ridges 
from which folds are given off which are arranged with regularity, and 
run obliquely upward and outward, to end in other indistinct lines on 
the sides of the canal. This arrangement of mucous membrane has 
received the name of arbor vitas. 

Between these folds numerous mucous glands are seen, their number 
in a well-developed virgin cervix being estimated at least at ten thou- 
sand. An occlusion of the ducts of these glands causes their distension 
with mucus, when they form small translucent cysts which either 
appear flat or project like peas from the surface of the cervix ; in the 
latter condition they are known as "ovula Xabothi," after the anat- 
omist Xaboth, who first described them. The mucous membrane form- 
ing these folds or rugae is covered by cylindrical and ciliated epithe- 
lium and studded by villi, which are found in considerable numbers 
upon the larger rugae and other parts of the mucous membrane. 

The natural secretion of the cervical canal has been shown by M. 
Donne to be alkaline, unlike that of the vagina, which is acid. 



PREDISPOSING CAUSES. 285 

Pathology. — Cervical endometritis consists in inflammation of all 
this structure and consequent alteration of its condition. The mucous 
glands are especially involved in the morbid action, the disease chiefly 
consisting in glandular inflammation. The glairy, mucus which is 
secreted in large amount as one of its symptoms is the characteristic 
discharge of these structures. Looked at with a strong glass in post- 
mortem examinations of this disease, they are seen enlarged and ele- 
vated, and their mouths may be seen very much dilated. In some cases 
it becomes complicated by granular degeneration. The villi or papillae, 
especially those on the vaginal face of the cervix, become diseased. At 
first there is a loss of the normal supply of epithelium, which produces 
a slight and very superficial abrasion. This becomes in time more dis- 
tinct and marked, from destruction of the villi themselves over spaces 
of greater or less extent. If this process of destruction should go on 
and affect the deeper tissues, a true ulcer would be formed, and no one 
would ever have denied the name of ulceration to the existing condition, 
but it does not thus progress. In time an hypertrophy occurs in the 
villi, which increase in size, project like so many hairs from the sur- 
face, and give to the os and cervix an appearance which has caused 
the term granular degeneration to be applied to it. This state affects 
the vaginal portion of the cervix chiefly, but may extend up the 
canal. 

Another pathological state which is occasionally met with as a com- 
plication of cervical endometritis is an eversion of the os and lower 
portion of the canal to such an extent as to keep up inflammation there 
by the friction of the membrane thus exposed against the floor of the 
pelvis. Some very obstinate cases are due to this condition. 

The diseased mucous membrane pours forth with great activity large 
amounts of thick, tenacious mucus, which is loaded with epithelium and 
sometimes tinged with blood. 1 

Predisposing Causes. — It is a matter of some moment that the eti- 
ology of this affection should be studied under two heads — predisposing 
and exciting. The former includes — 

Impoverishment of the blood from chlorosis or some other form 

of malnutrition ; 
Frequent parturition ; 
Subinvolution ; 
Styles of dress which depress the uterus. 

These influences either act injuriously upon the nervous system, 
and interfere with the circulation and nutrition of the lining membrane 
of the cervix, or by directly disordering the vessels and nerves of the 
uterus render it ready for the establishment of disease by some cause 
which would have exerted no baneful effect upon a woman in perfect 
health. 

It may naturally be asked why some of these influences should 
especially produce this disease. Our answer is, that they do not do so. 
Sometimes they cause chronic pneumonia ; at others times granular 

1 For a further description of the pathology of these products of cervical catarrh 
see the chapter on "Granular and Cystic Degeneration of the Cervix Uteri." The 
discussion of the latter subject might properly have been included in this chapter. 



286 CHRONIC CERVICAL ENDOMETRITIS. 

eyelids ; at others follicular pharyngitis ; and again at others chronic 
cervical endometritis. 

Exciting Causes. — Chief among these may be enumerated — 

Laceration of the cervix ; 

Displacements of the uterus, especially flexions ; 

Excessive or intemperate coition ; 

Puerperal endometritis ; 

Acute non-puerperal endometritis; 

Efforts at production of abortion and prevention of conception ; 

The use of intra-uterine pessaries. 
Many of the causes mentioned would fail to produce it in a uterus 
which had not been prepared for their action by depreciating constitu- 
tional conditions. When treatment is established for the cure of the 
disease, if it be inaugurated and pursued without regard to the predis- 
posing causes, it will often prove inefficient or futile in cases which 
would yield to a plan that showed a recognition of their importance. 
Appreciating highly, as we do, the value of local treatment in uterine 
affections, were we in the management of the disease limited entirely 
to one kind — local or general — we do not hesitate to say that we would 
infinitely prefer the latter. A removal from a city to the country, the 
use of mineral and vegetable tonics, plenty of good, nutritious food, 
the observance of regular hours, systematic exercise in the fresh 
air, and the pleasures of cheerful society, will, we feel confident, do 
far more for the patient than a weekly visit to the office of a phy- 
sician and the reception of the most appropriate local treatment which 
science can afford. But better than either plan is the judicious com- 
bination of the two. They should go hand in hand. Our wish is to 
keep prominent the fact that of the two the general treatment is the 
more important in the disease which now concerns us, as it is in many 
others which we shall come to consider. 

Symptoms. — Cervical endometritis may exist for a length of time 
without presenting any symptoms of sufficient gravity to warn the 
patient of its presence. Even a leucorrhoea which is somewhat abun- 
dant often fails to attract her attention. The answer to a question as 
to its existence will often be a negative one in cases in which the prac- 
titioner will, by the speculum, discover a considerable amount in the 
vagina. In the great majorit}^ of cases the disease will soon announce 
its existence by some or all of the following signs : The first symptom 
which will attract attention will probably be dragging sensations about 
the pelvis. These will soon be followed by pain in the back and loins, 
which will be very much increased by exercise or muscular efforts. 
Then a more or less profuse leucorrhoea will be noticed, the discharge 
as it issues from the vulva resembling boiled starch or thick gum-water, 
and often irritating the vulva and vagina to such an extent as to pro- 
duce inflammation in them. Menstrual disorders may now show them- 
selves. The discharge may be either too scanty or too profuse, too fre- 
quent or too infrequent, and to a certain extent painful ; sometimes, 
though not often, decided dysmenorrhea will exist. 

Usually, before the disease has existed for a long period, the con- 
stitution of the patient will show signs of becoming implicated. She 



PHYSICAL SIGNS. 287 

will become nervous, irascible, moody, and often hysterical. Her 
appetite will diminish and digestion grow feeble, so that impoverished 
blood will soon be observed as a result of impaired nutrition. With 
some or all of these signs of the existing disorder the patient may con- 
tinue for a length of time without suffering from others of more annoy- 
ing or graver character. Complications may, however, rapidly develop 
themselves; cystitis, cervical hyperplasia, and vaginitis coming on 
and proving exceedingly troublesome. At times pain during sexual 
intercourse constitutes a prominent sign of cervical disease, but it 
belongs rather to cervical hyperplasia than to endometritis, the former 
having added itself as a complication to the latter and thus pro- 
duced the symptom. Sometimes nausea, and even vomiting, present 
themselves as symptoms, and these, together with the digestive dis- 
order before mentioned, produce a deterioration in the nutrition of 
the patient. 

Although these symptoms are enough to make us confident of the 
existence of uterine disorder, they by no means furnish reliable grounds 
for a positive diagnosis. This can be arrived at only by physical 
exploration, 

Physical Signs. — The patient being placed upon her back, and 
the finger of the examiner introduced into the vagina, the os uteri 
will probably be found in its usual position in the pelvis, for the 
weight of the uterus is not increased, the connective tissue not being- 
involved. The os may be somewhat enlarged and its lips slightly 
puffed, or it may be roughened on account of granular degeneration. 
Sometimes, however, severe cervical endometritis may exist without 
enlargement of the os or any trace of abrasion or granular degenera- 
tion. If the finger be placed under the cervix and that part raised 
by it, pain will be complained of, though not to any great extent. 
This will be most marked opposite the os internum. No other affirma- 
tive sign can be elicited by this means, and the speculum should then be 
used. By this the os will be seen to be in the condition just described, 
and from it will be found to exude a long string of tough, tenacious 
mucus which will closely resemble the white of egg. If entangled by 
a small mass of cotton attached to the end of a whalebone rod, it will 
be found to be so viscid and resisting that it cannot be drawn from the 
canal. It will resist even a stream of water thrown with some force upon 
it, and very often is removed only after several efforts by this or other 
means. The cervix will usually be found to be somewhat enlarged. Its 
tissue may present a swollen, puffed appearance, or be intensely red, which 
will upon close inspection be found to be due to removal of its investing 
epithelium and the occurrence of hypertrophy of the villi. Should this 
condition exist, it will afford relief to the mind of the inexperienced gyne- 
cologist, for the diagnosis of the case will be clear. But another state 
of things may be discovered which will leave him in doubt. Upon 
removing the plug of obstructing mucus he may discover no evidence 
of disease. The os is no larger than it should be, its tissue is nor red- 
dened, no degeneration exists; in fact, nothing is found explaining the 
backache, nervousness, impaired nutrition, and profuse leucorrhcea 
which led him to advise and urge the examination. The case is sim- 



288 



CHRONIC CERVICAL ENDOMETRITIS. 




ply one of cervical endometritis, which affects the glands of the canal 
without abrading the lips of the os. 

In nulliparous women the cervical cavity is often very much dis- 
tended by the accumulation of thick cervical mucus, which is prevented 

from escaping by a small external os. 
The cervix then has an elliptic shape 
quite out of proportion to the size and 
shape of the body of the uterus. A 
probe inserted into the cervical canal 
enters a wide cavity bounded at the lower 
end by the external and at the upper by 
the internal os. 

It is often a matter of great difficulty 
to decide whether endometritis is con- 
fined to the neck or extends through this 
part into the body. In many cases a 
certain conclusion is impossible. The 
evidences by which it may be usually 
arrived at are these : In the former case 
the neck alone is found enlarged and 
tender to touch, conjoined manipulation, 
and the probe ; in the latter the body 
also shows these signs of implication of 

Dilated Cervical Cavity (diagrammatic), its tissues in the morbid action. The 

discharge resulting in the former is more 
thick, tenacious, and difficult of removal than in the latter variety. 
Lastly, the constitutional symptoms attending the latter are ordinarily 
graver than those created by the former. 

Course, Duration, and Termination. — Cervical endometritis is not a 
self-limiting disease, and consequently its duration will depend upon 
circumstances which control its progress. It may unquestionably dis- 
appear without medical aid. Any alterative influence which exerts a 
complete change in the economy — as, for instance, parturition, entire 
alteration of the habits of life, or some change equally decided — some- 
times results in a cure. But it is certainly safe to say that unchecked, 
it frequently passes in multiparous women into cervical hyperplasia, 
which would probably draw in its train displacement and all the long 
list of ailments which make the lives of women suffering from uterine 
disease so burdensome. 

Prognosis. — The prognosis of this affection will depend upon the 
degree of glandular disease accompanying it. If the mucus which 
marks inflammation of the glands be slight in amount and not very 
tenacious in character, the prognosis is favorable. When, on the 
other hand, a large amount of thick, yellow, resisting mucus hangs 
from the cervical canal, the prognosis, according to our experience, 
is very doubtful and sometimes hopeless, unless very radical meas- 
ures be adopted. If every practitioner will look back into his expe- 
rience, he will see that in all severe cases he has either been forced 
to resort for their cure to measures which absolutely destroy the dis- 
eased glands, or that the patients in time, wearied of his insuccess, 



TREATMENT. 289 

have gone for treatment elsewhere. Let it be remembered that we 
allude now only to very severe cases where the glands are profoundly 
involved. In regard to such we feel sure that the experience of others 
must agree with ours. 

Even in minor cases great caution should be observed as to fixing 
the time at which recovery will take place. Even in the mildest case, 
which has lasted for some time, from four to six months will probably 
elapse before perfect cure can be accomplished, and even after this a 
relapse will be very likely to occur unless preventive measures be 
adopted and strictly adhered to. 

Treatment. — The disease consisting in an inflammatory degeneration 
of the cervical mucous membrane, the efforts of the practitioner should 
be directed to producing an alterative influence upon that membrane 
and the avoidance of all influences which may cause it to spread to 
adjacent tissues. These ends will be best accomplished by the follow- 
ing means : 

General regimen ; 

Emollient applications ; 

Alterative applications ; 

Ablation or destruction of the diseased glands. 

General Regimen. — So far as this cause has any influence on the 
production of the disease under consideration, we can say that every- 
thing which is calculated to affect unfavorably the general health of 
the woman should be avoided or removed. Every function of her body 
should be regulated by the proper means known to those familiar with 
general medicine. Her hygienic surroundings should be improved. If 
she lives in damp, badly-ventilated apartments, these should be changed 
for a more salubrious dwelling. If necessary, vegetable tonics, mineral 
acids, and preparations of iron should be administered, regular daily 
exercise insisted upon, and good healthy, nourishing food, with the 
avoidance of indigestible articles and irritating spices and stimulants, 
provided for. In particular should attention be paid to proper regula- 
tion of the bowels, for which purpose a ferruginous tonic combined with 
a cathartic may be prescribed, as in the following mixtures : 

Ify. Magnesise sulphatis, ^ij ; 

Ferri sulphatis, gr. xvj ; 

Acidi sulphurici dil., 3j ; 

Aquae, Oj. — M. 

S. One ounce (two tablespoonfuls) in a tumbler of iced water every 
morning upon rising. 

1^. Sodre et potass, tart., sij ; 

Vini ferri ainari (U. S. D.), 5ij : 
Acidi tartarici, 3 i i j ; 

Aquae, |xiv. — M. 

S. One ounce in a tumbler of iced water every morning upon rising. 
19 



290 CHRONIC CERVICAL ENDOMETRITIS. 

Or, 1^. Massa Blaudi, 3ij ; 

Pulveris rhei, 3j ; 

Aloini, gr. v. 

S. Misce fiant pilulae No. xl. One after each meal. 

If there is much disturbance of the nervous system, with insomnia, 
excessive nervousness, together with loss of appetite, the following well- 
known prescription, the so-called "black mixture," may be found useful 
— namely : 

fy. Pepsinae (F. B. k F.), 31J ; 

Sodii bromidi, 3ss ; 

Carbonis animalis, 3j ; 

Aquae destillatse, ^viij- — M. 

S. Shake well. One tablespoonful after each meal, and before retiring 
if there is insomnia. 

If the appetite and digestion are disturbed, as is very liable to be 
the case, a mixture composed of the following will be found to be very 
beneficial : 

^. Pepsins, 3ij ; 

Acidi nitro-muriatici diluti, giss ; 

Bismuthi subnitratis, 3j ; 

Tincture nucis vomicae, 3j ; 

Vini Xerensis excellentissimi, ^viij. — M. 
S. One dessert-spoonful every three hours. Shake well. 

As a rule, whenever in cases of this kind the patient is found to be 
anaemic, neurasthenic, and in need of rest, the treatment indicated for 
these conditions and laid down in all the good textbooks on general 
medicine should be recommended. 1 

In former years we were in the habit of employing a number of 
palliative applications for the treatment of this disease, which, it is true, 
afforded some benefit, but seldom resulted in a complete or permanent 
cure. Among these were the familiar alterative applications of tincture 
of iodine, the iodized phenol, strong nitric acid, solution of persulphate 
of iron, solutions of nitrate of silver of various strengths, and even the 
solid stick of nitrate of silver and a strong solution of chromic acid. 
Undoubtedly, in some of these cases of a recent origin a cure was 
effected by these remedies, but we have come to the conclusion that in a 
disease so persistent and difficult of cure as is chronic cervical endome- 
tritis when it has existed for any length of time, it is a mere waste of 
time and trouble to attempt to cure it by the mild and pallative means 
above mentioned, and therefore during the past few years Ave have 
adopted the plan, in every decided case of this disease, of proceeding 
at once to the one radical means for effecting a permanent cure. We 
will briefly describe this as follows : In nulliparous women the external 
os is frequently so small that, as already mentioned, the exit of the 
excessive cervical mucus is prevented and the disease is thereby aggra- 
vated. In such cases we slit the external os by means of scissors or 

1 It may be given as a uniform rule, that the above directions for a tonic regimen 
apply equally to all diseases of the female sexual organs in which the general health 
of the patient is deteriorated and her nervous system worn out. 



TREATMENT. 



2<tt 



bistoury in four directions to a depth corresponding to the dilatation 
of the canal. We then excise with fine scissors the four flaps thus 
formed, and in this way the external os is left of a size equal to the 
width of the rest of the cervical ca- 
nal. In women who have borne 
children, especially if the lips of 
the external os have been lacer- 
ated, it is not necessary thus to 
open the cervical canal. 

The cervical cavity being freely 
exposed, we take one of the sharp 
curettes shown in Figs. 127, 129, 
and 140, and with it scrape the 
whole cervical cavity up to the in- 
ternal os, until we have removed 
every one of the diseased glands 
upon which the continuance of the 
secretion depends. Having thor- 
oughly mopped out the cervical 
cavity with cotton, so as to remove 
all blood and secretion and render it as dry as possible, we apply to it 
the pure nitric acid, being careful to touch every crevice and portion of 
the cavity. The vagina and the lips of the cervix are protected against 

Fig. 140. 




Crucial Incision of External Os. 




VvVv.SCWWWJT.H^ 



Simon's Sharp Curette. 



an excess of the acid by cotton packed around and under the cervix. 
The cervical cavity is then packed with a pledget of cotton covered with 
vaseline or with plain iodoform gauze, and the vagina with a tampon 
covered with iodoform or with iodoform gauze. 

It should be distinctly understood that this treatment is to be looked 
upon as an operation, and is to be performed only at the patient's resi- 
dence or at some spot where she can be immediately placed in bed, and 
if necessary to quiet her nervousness or ease her pain an anaesthetic 
should be given. After the operation we place an ice-bag over the 
hypogastric region, and keep it there for at least twenty-four hours, 
until all risk of inflammatory reaction has disappeared. The tampons 
from the vagina and cervix should be removed within forty-eight hours 
and replaced by similar ones, again to be removed in a like time : and 
when the slough from the cervical canal has separated applications o\' 
solution of nitrate of silver, one drachm to the ounce, or iodized phenol 
should be employed twice weekly until the cervical canal lias contracted 
to a normal size and all abnormal secretion has ceased. 

We have found this rather heroic and severe treatment vastly more 
successful and rapid in its effects than the old-time palliative mild caus- 
tic measures which we formerly employed; hence Ave have not thought 
it worth while to describe at greater length the latter remedies. 



292 



CHRONIC CORPOREAL ENDOMETRITIS. 



"We should not omit the recommendation of the persistent use of the 
hot vaginal douche given in the classic recumbent position twice daily 
during this whole treatment, whenever the vagina does not contain a 
cotton tampon. 

For the removal of the thick plug of mucus from the cervical canal. 
which it will usually be found difficult to dislodge, we would recommend 
the syringe with expanded orifice shown in the accompanying cut, and 
for applications to the dilated cervical cavity after the radical treatment 

Fro. 141. 




Mucus Syringe. 



the hard-rubber stick wrapped with cotton depicted in cut Fig. 142 will 
be found exceedingly useful. In very bad cases which have resisted 

Fig. 142. 




Hard-rubber Stick for Applications to Vagina and Cervix. 

the above measures the whole cervical mucous membrane, together with 
the underlying superficial muscular tissue, may be excised and the 
wounded surfaces brought together by deep sutures, the cervical canal 
being kept open by a glass or hard-rubber stem. 



CHAPTER XXI. 



CHEOXIC COEPOEEAL EXDOMETEITIS. 

Like the cervix, the body of the uterus is liable to chronic inflam- 
mation confined to its lining mucous membrane. This receives the 
name of chronic corporeal endometritis. 

Synonyms. — This disease has been described under the names of 
endometritis, uterine catarrh, uterine leucorrhcea, and internal metritis. 

Frequency. — Few points in uterine pathology have in former years 
created more discussion than this. Some excellent authorities regarded it 
as of rare occurrence, while a large majority considered it quite common. 
The late Prof. Byford 1 of Chicago, in his excellent work on Medical 
and Surgical Treatment of Women, said : " Inflammation limited to 
the cavity of the body of the uterus is not common, but I am quite 
sure that I have met with at least two instances.'" While Dr. Byford's 
experience furnishes him but two instances. Dr. Tilt gives the statistics 
of fifty cases of which he has kept notes, and Kloh declares the disease 
to be quite common. 

1 Op. cit.. p. 182. 



FREQUENCY. 



293 



The most frequent locality of uterine inflammation is that portion of 
the uterus below a line running across it through the os internum. The 
portion of the organ above this line, however, is much more commonly 
affected by inflammatory disease than was formerly supposed. We our- 
selves meet with what we are compelled from the subjective signs 
(escape of thin muco-serous or muco-purulent secretion from the exter- 

Fig. 144. 



Fig. 143 




\ 



Uterine Mucous Membrane : 
Longitudinal Sagittal Sec- 
tion. P,P, Peritoneum 
(from Beigel). 



• .;•. 



\ 




Uterine Mucous Membrane: Transverse Longitudinal Section 
(from Beige! j. 



nal os) and objective symptoms (heat, throbbing, and weight in the 
suprapubic region) to consider without doubt "chronic endometritis" 
proper, usually without evidence of involvement of the parenchyma of 
the organ — so frequently that we have long since ceased to question, not 
indeed its occurrence, but have instead marvelled that there could ever 
have been any doubt on the subject. The lining membrane of body 
and cervix are often simultaneously affected, and occasionally we find 
the disease limited to the body of the organ only. But usually, when 
only a portion of the uterus is thus affected, it is the cervix, which part 
is more exposed to the causes which produce catarrhal inflammation 
than the upper half of the organ. 



294 CHRONIC CORPOREAL ENDOMETRITIS. 

Anatomy. — If the mucous membrane of the uterus be examined with 
a lens, it will be seen to be studded with minute openings somewhat 
similar to the mouths of the glands of LieberkUhn in the intestines. 
These are the mouths of long, curling follicles, which project by their 
closed extremities downward toward the parenchyma of the organ. 
They are lined by delicate ciliated epithelium, their lining membrane 
consisting merely of involutions of that of the uterus. These glands 
are of two kinds : the simple, which are unbranched tubes ; and the 
compound, which have several branches. The complex racemose glands 
or mucous crypts, which sometimes become distended so as to form the 
so-called " channel polypus," are limited to the cervical cavity. 

Between these glands ramify numerous capillaries, which dip down 
and form a network about their mouths so superficial that they are 
sometimes seen by a strong glass completely uncovered, and even pro- 
jecting like villi into the cavity. 

Pathology. — Corporeal endometritis is, like the same affection in the 
cervix, a glandular disease. The utricular follicles are the seat of dis- 
order, and it is to the exaggeration f their secretory function that is due 
the uterine leucorrhoea which constitutes one of its prominent symptoms. 

The post-mortem appearances of the mucous membrane are these : It 
is found to be swollen, soft, pale, and smooth or covered over with gran- 
ulations. In cases which have lasted very long the utricular glands are 
in great numbers obliterated, or, atrophy having taken place at their 
mouths only, their secretions are retained and they are distended into 
cysts. In time the mucous membrane is replaced by a thin layer of 
connective tissue, which is covered not by cylindrical or ciliated epithe- 
lium, but by what resembles that of basement character. Frequently 
numerous small mucous polypi (so-called multiple adenomata) are found 
in the cavity, while at others, a closure of the os internum uteri having 
been effected by adhesion, hydrometra exists. 

[I have had three opportunities for examining post-mortem into the 
pathology of this disease. Two of these cases were presented to the 
Obstetrical Society of this city. In these instances the condition described 
by Scanzoni was most evident. The uterine cavity was found considerably 
enlarged, its walls diminished in thickness, and in one instance they were 
pronounced by Dr. J. B. Ke} T nolds. after microscopical examination, to be 
in a state of fatty degeneration. The uterine neck was in every case found 
healthy both as to parenchymatous and mucous structure, and the enlarged 
body displaced by anterior or posterior flexure. The mucous lining of the 
body was in two cases quite smooth, and to a great extent deprived of 
epithelium ; while in the third it was roughened, and presented points 
where the enlarged blood-vessels created a number of reddish spots. — 
T. G. T.] 

But enlargement of the uterine cavity is not always present ; it 
marks chronic cases, and will not be recognized in those of recent 
origin. It is highly probable, too, that in cases of recent origin the 
pathological appearances which have been here described would not be 
found to exist, but in place of them a thickened, congested, and florid 
appearance would present itself. 



CA USES. 295 

Prognosis. — The prognosis of chronic inflammation of the mucous 
lining of the uterine body is always grave with reference to cure. Even 
if the case be not of very serious character and have lasted only a short 
time, the possibility of rapid recovery is doubtful, while, if it have con- 
tinued for a number of years, it will often prove incurable. Scanzoni l 
says, with a candor which does him honor, u As for ourselves, w r e do not 
remember a single case where we have been able to cure an abundant 
uterine leucorrhoea of several years' standing." In most cases a cer- 
tain amount of amelioration may be effected even when they are of long 
standing ; in a certain number treated early cure may unquestionably 
be accomplished ; while in a great many nothing whatever, either in 
the way of cure or of relief, can be obtained, and the patient, after 
passing from physician to physician, settles down into a careful mode 
of life, resolved to cease treatment and bear as best she may an evil 
which she has learned to regard as incurable. 

The symptoms of a favorable and an unfavorable case of corporeal 
endometritis may be thus contrasted : 



Prognosis is Favorable when — 
The case is of recent standing ; 
The discharge is of mucus or blood ; 
Dysraenorrhoeal shreds are not cast off; 
Patient naturally of strong constitution 
Connective tissue is not affected : 
Dimensions of cavity are not increased 

Nervous system is not involved ; 
Patient near menopause. 



Prognosis is Unfavorable when — 
The case is of long standing ; 
The discharge is purulent ; 
Dysmenorrhoeal shreds are cast off; 
Patient naturally of feeble constitution ; 
Connective tissue is affected ; 
Dimensions of cavity are decidedly in- 
creased ; 
Nervous system is involved ; 
Patient not near menopause. 

Predisposing Causes. — It has been noticed most frequently to 
have developed itself in women showing a tendency to the following 
conditions : 

Scrofula ; tuberculosis ; spansemia ; 

Too frequently-repeated parturition ; 

Exhaustion from lactation ; 

Great and prolonged nervous depression. 
JExciting Causes. — These may be enumerated as follows : 

Exposure during menstruation ; 

Sudden checking of the menstrual flow ; 

Obstruction to escape of menstrual blood ; 

Subinvolution after parturition or abortion ; 

Cervical endometritis ; 

Acute endometritis, puerperal or not ; 

Displacements causing great congestion ; 

Chronic pelvic peritonitis ; 

Abuse of sexual intercourse ; 

Injury from sounds or intra-uterine pessaries, and injuries 
resulting from attempts to produce abortion ; 

Certain diseased conditions of the blood, as those accompany- 
ing phthisis and the exanthematous diseases ; 

Tumors in the uterine cavity or walls : 

Vaginitis, specific or simple. 

1 Scanzoni, Diseases of Females, Am. ed., p. '202. 



296 CHRONIC CORPOREAL ENDOMETRITIS. 

It is quite clear how either of the first two causes in checking 
hemorrhage from the congested mucous lining of the uterine body may 
at once induce the first stage of the disease. They generally result in 
the acute variety, which passes off rapidly, but which sometimes ends 
in the chronic form. 

Obstruction to escape of menstrual blood is a very fruitful source of 
the affection. The menstrual blood, if it pours at once into the vagina, 
remains fluid from admixture of an acid mucus secreted by the lining 
membrane of that canal ; but if it be imprisoned in the uterine cavity, 
where only an alkaline mucus exists, it very soon becomes clotted. 
These clots are too large to pass through a cervix of normal dimensions, 
and of course cannot escape from one unnaturally constricted. Their 
presence in the uterine cavity, together with that of blood which they 
imprison, in time excites contraction, by which they are expelled. This 
repeated dilatation and contraction cannot last long without exciting 
inflammation in the mucous membrane of the uterus. Such an obstruc- 
tion may have as its cause a small polypus which acts as a ball valve at 
the os internum, congenital or acquired narrowness of the cervical canal, 
or uterine flexion. 

The parturient process is a very frequent source of the disease, 
especially where the undeveloped placenta is prematurely separated from 
its uterine connection. Where in a prolonged labor the early evacua- 
tion of the liquor amnii leaves the irregular outline of the body of the 
child pressing against the uterine investment for many hours, such a 
sequel might result. 

We have already stated our belief that a cervical inflammation 
rarely spreads upward into the uterine canal unless it be of a specific 
character ; still, we will not deny the possibility of that occurrence. 

Acute endometritis may, instead of subsiding entirely, very naturally 
run into this disease. 

Subinvolution of the uterus keeps up a constant tendency to hyper- 
emia of the parenchyma which affects the mucous membrane. Indeed, 
the latter may take part in the process of deficient involution which 
affects the uterine parenchyma. As a complication of this condition 
corporeal endometritis is more commonly observed than as a consequence 
of all the other causes combined. 

Pelvic peritonitis disturbs the position, the innervation, and the 
circulation of the uterus, and proves a fruitful source of endome- 
tritis. 

The effect of sexual intercourse as a causative influence is frequently 
observed soon after marriage, the first connubial approaches exciting 
uterine congestion with greater or less intensity. This statement 
applies chiefly to women who, having enfeebled their systems by habits 
of indolence and luxury, pressed their uterus entirely out of the normal 
position, and perhaps gone to the nuptial bed with some lurking uterine 
disorder, the result of imprudence at menstrual epochs, naturally are 
in no condition for sexual intercourse, and of course suffer in conse- 
quence. The taking of food into the stomach exerts no injurious 
influence on the digestive system, but the taking of food by a dyspeptic 
who has abused and injured the organ may do so. 



SYMPTOMS. 297 

Injuries from sounds, etc. act so evidently in exciting inflammation 
as to need only mention. 

Certain conditions of the blood sometimes produce acute corporeal 
endometritis, which, as already stated, may pass into the form under 
consideration. As a complication of the exanthematous diseases endo- 
metritis is well known, and its occurrence with phthisis has been noted 
by many practitioners. 

Tumors in the cavity or walls of the uterus very generally produce 
this disease in consequence of the congestion of the mucous membrane 
which they cause. 

Vaginitis of non-specific character may, and of specific form often 
does, pass by continuity of structure into the neck and body of the 
uterus. The latter has in these cases in our experience not only 
affected the body, but the Fallopian tubes, resulting in peritonitis. 

Symptoms. — The symptomatology of corporeal endometritis consti- 
tutes one of the most unsatisfactory and obscure subjects in the entire 
field of gynecology. At times its symptoms are so light and at others 
so masked and obscure that the disease often runs a lengthy course 
without exciting the suspicions of either physician or patient. Its 
effects upon the constitution also differ most unaccountably in different 
cases. Sometimes the disease will continue for ten, fifteen, or twenty 
years, producing profuse leucorrhoea, menstrual disorders, and nervous 
derangement, and yet result in no annoyance so grave as to cause the 
patient to seek medical aid. At others it accompanies or excites 
areolar hyperplasia, which induces displacement and causes pain on 
locomotion, sexual intercourse, and the passage of feces through the 
rectum ; or results in an ichorous discharge, which creates the annoying 
symptoms of vaginitis, cystitis, or pruritus vulvae. The chief symp- 
toms which usually present themselves in a case of mucous inflammation 
of the uterine body are — 

Leucorrhoea ; 

Menstrual disorders ; 

Pain in the back, groins, and hypogastrium ; 

Throbbing, weight, heat, and bearing-down in the suprapubic 
region ; 

Nervous disorders ; 

Reflex neuroses ; 

Sterility. 
Profuse leucorrhoea of thin, serous, muco-purule'nt, or muco-serous 
character is one of the chief signs of the affection. If the secretion 
is very tenacious and thick, it is the product of the cervical glands only. 
Very frequently, especially soon after menstruation, the discharge is 
brownish or rust-colored, and is then most likely to attract the atten- 
tion of the patient. This is, however, by no means a pathognomonic 
sign, being met with in cases of retention of fragments of ovum after 
abortion and in laceration of the cervix. Sometimes the menstrual dis- 
charge is regarded by the patient as greatly prolonged, when in reality 
it is this blood-stained leucorrhoea which follows the process of menstru- 
ation that gives rise to the belief. In some instances the discharge is 
milky, and at others — and these are the most rebellious cases — distinctly 



298 CHRONIC CORPOREAL ENDOMETRITIS. 

purulent. There is a variety of corporeal endometritis which occurs in 
old women who have long ceased to menstruate, in which a watery or 
creamy pus is secreted. This is known as the senile form of endome- 
tritis. These cases are often accompanied by the most wearing and 
harassing pruritus vulvae. 

Menstrual disorders are rarely absent. The discharge is sometimes 
too profuse, even lasting throughout the month and constituting nienor- 
rhagia, or it is very scanty and shows a marked tendency to cessation. 
A characteristic of these cases of scanty and irregular menstruation is, 
that the women are inclined to grow fat and develop a decided anaemia. 

Where the connective tissue is entirely unaffected menorrha^ia may 
occur without pain, but this is not common, for that tissue is often simul- 
taneously involved and dysmenorrhcea coexists. Sometimes in these cases 
an exfoliation of the entire lining membrane of the cavity of the uterine 
body occurs at the menstrual periods. This has received the name of 
the dysmenorrhceal membrane, and is by some regarded as an evidence 
of chronic corporeal endometritis. 

Pain in the back, groins, and hypogastrium is generally present, and 
at times a burning sensation over the symphysis pubis proves a source of 
great discomfort. 

Nervous symptoms of greater or less severity generally show them- 
selves before the disease has lasted long. The patient complains of 
neuralgic headache, especially over the crown, hysterical symptoms, 
with sadness, tendency to weep, and a feeling of intense isolation and 
incapacity for any mental effort. 

Meteorism is a very common symptom, the connection of which with 
inflammation of the uterine mucous membrane is not at first glance 
clear. It is probably due to disorder of the nervous influences govern- 
ing peristalsis and giving tone to the intestinal muscular tissue, which 
proceeds to such an extent as to result in accumulation of gases in the 
canal. In the same way this affection may induce constipation, which 
is often one of its most obstinate accompaniments. 

Symptoms of pregnancy often exist in connection with the disease, 
and sometimes mislead the physician. Nausea and vomiting are by no 
means invariably present, but are valuable signs. They appear to result 
from this disease, as they do from occupation of the uterine cavity by 
the product of conception. Sometimes in addition to these there are 
darkening of the areolae of the breasts and enlargement and sensitive- 
ness of the mammary glands. When to these are added abdominal 
enlargement from tympanites and irregularity of menstruation, it will 
be perceived how easily an error might be made. 

Sterility is so commonly a result of endometritis that it should be 
considered as one of its signs. Very often it has been the only symp- 
tom that has led to an investigation of the state of the uterus which has 
determined the existence of the disease. The affection does not, how- 
ever, preclude the possibility of conception : it only diminishes the 
probability. 

Physical Signs. — The physical signs are neither numerous nor reli- 
able. Those of real value only will be mentioned. The uterine probe 
passed into the cavity will often show the length of the uterus to be 



TREATMENT. 299 

greater than it would be in health, and create more discomfort than in 
a healthy uterus. In addition to the decided increase of pain on probing 
or sounding the uterus, there is also a much greater disposition on the 
part of the endometrium to bleed after this manipulation, which is nat- 
urally accounted for by the greater vascularity of the mucous membrane. 
Upon conjoined manipulation, two fingers being placed in the fornix 
vaginae and the fingers of the other hand made to depress the anterior 
wall of the abdomen, sensitiveness will usually be found in the body of 
the organ. The recognition of the absence of cervical disease, while at 
the same time there are profuse uterine leucorrhoea and the other symp- 
toms recorded, will lead us strongly to suspect corporeal endometritis. 
Lastly, dilatation of the os internum may be taken as a corroborative 
sign. In the absence of cervical catarrh the presence of an erosion of 
the lips of the external os would also indicate corporeal endometritis. 

Diagnosis. — In addition to the subjective signs already referred to 
(weight, throbbing, bearing down in the hypogastric region, thin, muco- 
purulent, more or less pungent and irritating leucorrhoeal discharge, at 
times rusty, or sanious secretion), the physical signs are best discovered 
by ocular inspection through the speculum. They may be recapitulated 
as eroded lips of external os, thin discharge with above characteristics 
from the cervical canal, tenderness and ready bleeding on probing or 
sounding. Unusual tenderness and softness of the body of the uterus 
on bimanual examination should also be mentioned as a sign. 

Course, Duration, and Termination. — This disorder often lasts for 
years, in the case of a nulliparous woman confining itself to the mucous 
membrane ; in that of a woman who has borne children gradually excit- 
ing congestion and exuberant growth in the subjacent parenchyma. 
This is the most frequent result exerted upon the parenchyma, but 
it may be affected in two ways : first, a hyperplasia, or excess of nutri- 
tion, may occur ; second, an aplasia, or want of nutrition, may take 
place, and dilatation and distension eventuate. 

Complications. — The most ordinary complications met with are dis- 
placement, vaginitis, and pruritus vulvas. In aggravated cases a 
catarrhal inflammation of the Fallopian tubes and a chronic congestion 
of the ovaries are very likely to accompany the disease of the endo- 
metrium. 

Treatment. — Special attention should be given to sustaining and 
improving the general health of the patient, which will often show a 
marked tendency to depreciation. Good diet, fresh air, systematic 
exercise, and avoidance of all circumstances calculated to depress the 
spirits or harass the mind should be recommended. If practicable, 
change of air and scene should be brought to our aid, and the patient 
be sent occasionally to some suitable watering-place or country resort. 
The healthy condition of the nervous and sanguineous systems will be 
fostered by these measures, and should medicinal tonics bo required, 
iron, the mineral acids, quinine, the bromide of potassium, or mix 
vomica may be administered. All rich and highly-spiced food should 
be avoided, and the patient should be guarded against habits of indo- 
lence and luxury, which tend to exhaust the nervous strength. 

The uterus should be placed at rest by removal of pressure upon 



300 CHRONIC CORPOREAL ENDOMETRITIS. 

the fundus by clothing, limitation of marital intercourse, avoidance 
of violent and intemperate exercise, and, if necessary, by a sustaining 
pessary. Should absolute displacement exist, it should be carefully 
rectified ; a laceration of the cervix would call for its repair ; and in 
case uterine enlargement or subinvolution be present, ergot in small 
doses should be systematically administered. 

Applications to the Uterine Cavity. — Upon theoretical grounds 
direct applications to the diseased endometrium would hold out a 
brighter promise of cure in these cases than any other plan of treat- 
ment, and during the past quarter of a century it has become the con- 
ventional habit to recommend them. [In this habit I have shared, 
until closer observation and enlarging experience during the past five 
years have led me to become skeptical as to the utility of the course. 
Observation and experience have so changed my own practice that I 
find myself very rarely resorting at present to applications, above the 
os internum uteri. That they may become necessary in certain cases 
I do not at all deny ; but I maintain that they should not be habit- 
ually resorted to — first, because they very generally fail in curing the 
disease ; and, second, because they are by no means void of danger. 

That a certain number of cases of pelvic peritonitis and cellulitis 
are created by these applications all must admit. In spite of this fact, 
their use would be decidedly indicated were their results very promising. 
But in my experience their results are not promising, and for this rea- 
son I have given up their general use. I shall nevertheless describe 
the methods by which such applications should be made as fully as 
seems necessary. — T. G. T.] 

Recamier was the first who had the boldness to cauterize the cavity 
of the uterus, which he did by means of nitrate of silver in an ordinary 
porte-caustique. The practice thus introduced was continued and 
spread abroad by Robert, Richet, Trousseau, Maisonneuve, and others, 
but to-day the introduction of solid caustics into the uterine cavity is 
very rarely resorted to. There are four methods by which intra-uterine 
cauterization may be practised : First, by the use of solutions painted 
over the surface ; second, by ointments left to melt in utero ; third, by 
injections of fluid into the cavity of the body ; fourth, by solid caustics. 
In commencing treatment the practitioner should see that the cervical 
canal is well opened, in order to admit the free escape of fluids from the 
cavity above and the application of substances through it from below. 
This perviousness, if it do not exist, should be secured by the use of 
dilators before the local treatment is proceeded with. If the uterus be 
found sensitive to vaginal and rectal touch, the patient should remain 
in bed for some days before the first application is made, the bowels be 
kept active by mild saline purgatives, and warm baths or hip-baths 
with copious vaginal injections employed. If the operator use the 
ordinary long, cylindrical speculum, he will in the majority of cases fail 
to accomplish the end in view, reaching the fundus uteri, for through 
such an instrument it is always difficult to penetrate so high into the 
cavity. If, however, he uses the Sims speculum or one of its modifica- 
tions, or a short, cylindrical instrument, he will succeed without effort 
or delay. The instrument being introduced and the cervix cleansed 



INJECTIONS INTO THE UTERINE CAVITY. 301 

by the mucus syringe, the operator very gently passes through the cer- 
vical canal a small and delicate silver or hard-rubber tube attached to a 
long handle. Through this tube the applications are to be made. This 
silver tube is not, however, essential, since by careful cleansing of the 
canal the saturated cotton-wrapped applicator can usually be passed to 
the fundus, with a fair prospect of carrying in enough of the medicinal 
fluid to eifect the desired object. The usual patulousness of the uterine 
canal in these cases facilitates this procedure. 

Having previously wrapped the silver or hard-rubber probe with a 
film of cotton, he now passes this up to 1 the fundus. This removes a 
good deal of mucus from the cavity which would otherwise have neu- 
tralized the caustic introduced. Removing the cotton from the probe, 
he wraps another piece around it, or, as is better, uses another probe 
already wrapped, and, dipping this into the fluid caustic which he has 
determined to use, he passes it directly to the fundus and gently moves 
it over the surface. This should not be repeated, for the astringent 
action of the caustic makes repetition difficult, and if properly done the 
first time it will be unnecessary. After this the patient should go to 
bed, and remain perfectly quiet until the next day at least, and if any 
discomfort exist for several days. 

In place of the cotton-wrapped probe the painting of the uterine sur- 
face may be very thoroughly accomplished by the use of a small brush 
of pig's bristles dipped in the solution and passed through the cervical 
speculum. 

The alteratives which may be thus employed are — 

Solution of chromic acid, gj to ^j water ; 

Solution of nitrate of silver, ^j or £ss to ,%j of water ; 

Compound tincture of iodine, ^ss to ^ss of glycerin ; 

Saturated solution of sulphate of zinc ; 

Saturated solution of sulphate of copper ; 

U. S. D. solution persulphate or perchloride of iron with equal parts of glycerin ; 

Solution of chloride of zinc, £j to ^j water ; 

U. S. D. muriate tincture of iron, ^ij to ^j water ; 

Concentrated solution of carbolic acid. 

Ointments. — Medicated ointments have been employed by various 
physicians to the uterine cavity, but have now fallen completely into 
disuse. They have no special advantage over fluids, and are much 
more troublesome to apply. 

Solid applications to the endometrium are also but seldom used at 
present, the old practice of pushing pieces of nitrate of silver into the 
uterine cavity, and leaving them there to melt, being both too painful 
and dangerous, and besides likely to cause undesirable cicatricial con- 
traction of the uterine canal. The same objection applies to the cauteri- 
zation of the endometrium with nitrate of silver fused on a silver probe. 

Intra-uterine pencils containing zinc, copper, alum, or iron in sub- 
stance, and kept suspended by the addition of tragaeanth or cacao 
butter, were also formerly used. 

Injections into the Uterine Can't//. — In the last edition of this 
book we devoted several pages to a careful review of the history, indi- 
cations, and counter-indications of this method of treating catarrh of 



302 CHRONIC CORPOREAL ENDOMETRITIS. 

the endometrium, and we will refer the reader who may feel interested 
in the subject to that chapter. Since then this practice has fallen 
almost entirely into disuse, and it is hardly worth while at the present 
day to spend very much time or labor on its description. Suffice it to 
say that intra-uterine injections were employed as long ago as in the 
year 400 b. c. by Hippocrates, and they are advised by numerous 
writers of different countries even down to our time. While the dan- 
gers of these injections, consisting mainly in uterine colic, severe shock, 
prostration, pelvic and general peritonitis from escape of the fluid into 
the peritoneal cavity through the Fallopian tubes, were recognized by 
the earlier authorities, there were still numerous advocates of the 
method, notable among whom were Recamier, Yelpeau, and Ricord in 
France ; Routh, Matthews Duncan, and Tilt in England ; Siegmund, 
Braun, and Martin in Germany ; and Nott and Kammerer in this coun- 
try. In course of time, however, so many cases of dangerous symp- 
toms, and even death, following the treatment were reported that its 
opponents ultimately by far outnumbered its adherents. Fatal cases 
of peritonitis have occurred to Bretonneau, Nelaton, Gubiau, Noeg- 
gerath, Haselberg, Jobert, and others, and the cases of dangerous 
peritonitis ending in recovery which have been produced in this man- 
ner are too numerous to mention. The dangerous results of intra- 
uterine injections appear to be due not so much to the character of the 
fluid employed as to forcible dilatation of the uterine cavity on the one 
hand, even though apparently no force was used and the quantity of 
fluid injected consisted of but a few drops, and to the undoubted occa- 
sional passage of the fluid through the Fallopian tubes. It was 
thought, therefore, that if the uterine canal were widely dilated, so 
that the fluid could escape freely from the external os as soon as it 
was injected, both the colic and shock produced by the distension of 
the uterine cavity and the entrance of the fluid into the tube could be 
avoided ; hence the more recent adherents of this method made it a 
universal rule that the uterus should first be dilated by tents or diver- 
gent dilators, so as to permit the injected fluid to escape immediately 
after its introduction. Undoubtedly, many accidents have been and 
can be avoided by a careful observance of this precaution ; and it is 
for this reason that some of the German authorities still recommend 
and practise intra-uterine injections. The late Prof. Schroeder, we 
know, employed it, and B. Schultze, Martin, and Winckel still make 
frequent use of it. We, for our part, while never fearing to irrigate 
thoroughly with plain water or mild medicated solutions the interior of 
the puerperal uterus, confess that we have not had the boldness, in 
view of the many unpleasant experiences of others and the few of our 
own, to continue irrigation or injection of the non-puerperal uterine 
cavity. We regret having been obliged to arrive at this conclusion, 
since there is no other equally efficient and thorough method of apply- 
ing medicated solutions to the interior of the uterus. 

Having thus stated our objection to this form of treatment, we 
will spare the reader the details given in our last edition as to how 
such injections are to be used and what solutions should be em- 
ployed. 



INJECTIONS INTO THE UTERINE CAVITY. 303 

It may now be asked, since we oppose the habitual practice of 
carrying applications above the os internum uteri as well as that of 
injecting the uterine cavity, what course we do advise and adopt in the 
management of this affection. As we have already stated, we would 
recommend careful attention to the general state, removal of displace- 
ments, cure of laceration of the cervix, extirpation if possible of any 
existing neoplasm, and, if uterine enlargement exist, the free use of 
ergot. To favor the free escape of mucus from the uterine cavity we 
would see that the cervical canal be dilated. And now, if improvement 
did not occur, we would apply the dull wire curette freely over the 
whole surface. In speaking of the pathology of corporeal endometritis 
it was stated that the diseased membrane in time develops upon its sur- 
face fungoid granulations, mucous cysts, and mucous polypi. These 
secondary conditions often result in metrorrhagia or monorrhagia. Not 
only does the gentle application of the little wire curette without cut- 
ting edge accomplish the removal of these, but it produces, when 
thoroughly applied, an altered state in the entire endometrial membrane, 
breaks distended blood-vessels, and often accomplishes a great deal for 
the relief of the disease. In cases of endometritis engrafted upon sub- 
involution and accompanied by hemorrhage it is especially applicable. 
But its beneficial results depend, we feel sure, upon the fracture of tor- 
tuous and distended blood-vessels, and it is chiefly for this purpose that 
we use it. 

The use of the dull wire curette does a greater amount of good in 
these cases at the expense of less risk than the applications just men- 
tioned, and we infinitely prefer it. 

[With the exception of condensing the portion of the present chapter 
relating to the treatment of chronic corporeal endometritis, especially that 
treating of intra-uterine injections, I have substantially retained the views 
of the author, with which to a great extent I perfectly agree ; but I am 
not willing to place myself on record, in the light of my own personal 
experience, as sharing the sweeping condemnation which he has passed 
upon the intra-uterine treatment of this disease by chemical agents. 
I admit that in the absence of intra-uterine irrigation with medicated 
fluids, and of the introduction of solid chemical agents into the uterine 
cavity, the remaining methods of intra-uterine medication by no means offer 
us the ideal treatment for uterine catarrh. The reason for this failure is 
chiefly the impossibility of making thorough applications of fluids to the 
interior of an undilated uterus, since the fluid introduced on applicators of 
metal or hard-rubber wrapped with cotton is mostly squeezed out, and thus 
very little of it really reaches the uterine cavity proper in the majority of 
cases in which such applications are made. It is true, we might dilate the 
uterine cavity, and thus be enabled to thoroughly apply the medicinal agent 
to every portion of it, but as the majority of cases of chronic endometritis 
come to our offices for treatment, and as dilatation of the uterine canal suffi- 
cient to allow its thorough treatment is not feasible or safe in the office, and 
further, as but few such patients would be willing to undergo the confinement 
to bed and the thorough radical treatment then to he employed, considering 
with some justice that the treatment was worse than the disease, we are 
unfortunately unable to give a large proportion of such cases the benefit of 
the best means at our disposal ; and still T have seen so many cases o\' 



304 CHRONIC CORPOREAL ENDOMETRITIS. 

chronic endometritis with subinvoluted hyperplastic uteri in which I have 
been enabled, by a persistent course of intra-uterine applications of tincture 
of iodine or tincture of iodine and carbolic acid equal parts, through a period 
of several months, to relieve the most distressing symptoms at least, if not 
cure the endometritis permanently, that I should feel sorry to be compelled 
to give up this method of treatment unless something equally beneficial and 
not more troublesome were substituted. I see no reason why the mucous 
membrane lining the cavity of the uterus should not be treated on a similar 
principle as that clothing the throat, nares, male urethra, rectum, or other 
accessible cavities of the body ; and no one will deny that topical applica- 
tions of astringents or caustics, alteratives, or styptics exert a most bene- 
ficial, and even decidedly curative, effect on these mucous tissues. The 
question in the uterus seems to me simply to be one of rendering the endo- 
metrium accessible to the application. My plan in severe cases of chronic 
endometritis has been briefly the following : If the patient can be induced 
to spend a few days or a week even in bed, I have, if necessary, given her 
an anaesthetic, placed her in Sims's position, and through Sims's speculum 
have under proper aseptic precautions scraped her endometrium carefully, but 
thoroughly, with the blunt curette, or at times even with the sharp curette, 
having first dilated the canal with Palmer's dilator ; I have then mopped it 
dry by means of a cotton-wrapped applicator, and have then applied on a 
similar applicator a solution of chloride of zinc of a strength of 50 per cent, 
to the whole endometrium ; and I have repeated this same application two 
or three times, if necessary, until all oozing had stopped. I then introduce 
a cylindrical wad of cotton covered with iodoformed vaseline into the uterine 
cavity, to effect separation of its walls, and place an iodoform tampon over 
the cervix. The patient is put to bed, an ice-bag is kept over the hypogas- 
trium for twenty-four hours or as long as pain exists. After forty-eight 
hours the tampon is removed from the vagina and the uterus, and douches 
of hot water are given twice daily in the usual fashion. If all pain has 
subsided, the patient is allowed to leave her bed toward the end of a week, 
and future applications of a solution of 20 per cent, chloride of zinc are 
made once every week or ten days at the office. From three to six of these 
applications will usually bring about such a revolution in the nutrition of 
the uterine mucosa that a fresh and healthy membrane will take the place 
of the one that was diseased and destroyed. If necessary, however, milder 
applications of a solution of nitrate of silver, one drachm to the ounce, may 
be continued once or twice a week for several weeks. "When vegetations 
were present in the endometrium they were of course removed by the 
curette as described, and if menstruation had been very profuse, in place of 
the chloride of zinc I have found the iodized phenol or compound tincture 
of iodine, applied in the same manner, very useful. These applications should 
be repeated more frequently than those of the zinc — that is to say, about 
twice a week. In the treatment of chronic endometritis of a milder type, 
in which the patients could not be induced to undergo this more severe if 
more efficient treatment, I certainly have seen a decided benefit result from 
the use of intra-uterine applications of iodized phenol, tincture of iodine, 
or carbolic acid and glycerin equal parts. Even if the endometritis was 
not much benefited, not to speak of cure, the applications by their stimu- 
lant and alterative effect upon the uterus, in my opinion, certainly relieved 
congestion of that organ and tended to diminish subinvolution and hyper- 
plasia. Where there was much discharge, but no particular tenderness, or 
where there was a tendency to profuse menstruation, I have found pencils 
containing five grains each of powdered alum and iodoform covered with 



INJECTIONS INTO THE UTERINE CAVITY. 305 

gelatin very useful. It is important, of course, that the gelatin should be 
soft and the pencils always flexible, so that they will melt very soon after 
their introduction. I have had them made by Robert E. Fleischer of 
Seventy-first street and Second avenue, and I believe Parke, Davis & Co. 
furnish a similar article. Unfortunately, so far, the chemists who experi- 
mented with the manufacture of these pencils have not been able to make 
them for me with iodine or carbolic acid or iron, so as to ensure the gelatin 
retaining its softness and solubility. I insert these pencils into the cavity 
of the uterus proper by means of a piston tube, and retain them by a tam- 
pon placed against the cervix. 

Some years ago I thought I had found the ideal method of making 
applications of fluids in the uterine cavity. The syringe which I had made 
for this purpose was composed of hard rubber, with a fine uterine tube two 
inches in length with numerous small perforations. The plan of this sy- 
ringe was not original with myself, a similar one made of silver for intra- 
uterine injections having been shown me at the instrument-maker's as the 
invention of the late Dr. F. D. Lente, but I believe my plan of using it 
was original ; at least it was so with me. The syringe was filled with the 
solution to be employed, usually iodine or carbolic acid or one of the other 
applications (I have even applied nitric acid in this manner), and then the 
uterine tube was wrapped with a thin film of absorbent cotton and the sy- 
ringe introduced into the uterus through a speculum. By gently propelling 
the piston with a very slow rotary motion the fluid was gradually forced 
into the cotton, which became thoroughly saturated with it and necessarily 
touched every portion of the endometrium. There could be no doubt of 
the entire thoroughness of this method of application. Any excess of 
fluid readily flowed out of the external os, but by previous experimenta- 
tion it was easy to ascertain exactly how far the piston should be advanced 
in order to saturate the cotton, so that anything like the forcing of an 
excess of fluid into the cotton, which would practically resemble an injec- 
tion, could be avoided. I used this method many times with great satisfac- 
tion, and without either immediate or subsequent bad results, until once, 
making an injection of a solution of nitrate of silver, one drachm to the 
ounce, the patient was seized, quite unaccountably in my opinion, with 
severe uterine colic and shock, fortunately of merely temporary duration ; 
but when this same accident had happened to me three or four times in 
different patients, in one case requiring a hypodermic of morphine and the 
conveyance of the patient to her home in a carriage and rest in bed for 
several days, with symptoms of threatened peritonitis, I confess that I began 
to mistrust the entire safety of the practice, no matter how much confidence 
I might have in its efficiency, and I gradually gave it up, so that during 
the last few years I have no longer employed it, but have returned to the 
old-fashioned method of application described above. From this I have, to 
my recollection, never seen any bad results. 

In some cases quite severe hemorrhage follows the use of the curette, 
even the dull instrument, and at times we find a soft, spongy, subinvoluted 
uterus so liable to bleed from the mere introduction of the sound or probe 
that it seems unsafe to allow the patient to return home without providing 
against a continuance or return of the bleeding. In such cases 1 have fre- 
quently resorted to the tamponade of the uterine cavity, inserting a conical 
wad of cotton soaked in a solution of liquor ferri subsulphatis and glycerin, 
equal parts, or of compound tincture of iodine, into the uterus In means 
of a slide applicator (see Fig. 145) ; and I have either removed it myself 
after twenty-four or forty-eight hours or enabled the patient to withdraw 

20 



306 AREOLAE HYPERPLASIA, OE CHRONIC METRITIS. 

it by means of a string tied around it. I should be sorry to be obliged to 
dispense with this method of treatment in appropriate cases. 

In addition to the intra-uterine applications. I always follow the author's 
recommendations as to the attention to the general health, removal of dis- 




Slide Applicator for Tamponade of Uterus. 

placements, and. in fact, the treatment and if possible cure of the uterine 
and pelvic congestion. For that reason regulation of the bowels, moderate 
exercise in accordance with the rules governing intra-uterine treatment 
(that is, on the day of such treatment I usually enjoin patients to take 
very little if any exercise, and at once on returning home to rest for an hour 
or two or as long as pain persists), abstinence from marital intercourse, the 
use of iron with or without ergot, massage, etc.. form the routine measures 
which go hand in hand with the local treatment. Without these, no doubt, 
many a case of chronic endometritis in which the original cause of the 
catarrh is more of a constitutional than of a local nature would remain un- 
cured ; but I am confident that the reverse is equally true, and that very 
many cases would resist all general measures unless the local condition upon 
which the continuance of the catarrh depends is removed by appropriate 
local treatment. — P. F. M.] 



CHAPTER XXII. 

AREOLAR HYPERPLASIA OF THE UTERUS— THE SO-CALLED CHROXIC 
PARENCHYMATOUS METRITIS. 

Definition and Nomenclature. — One of the most common patholog- 
ical combinations which confronts the gynecologist is that which we here 
endeavor in as concise a manner as possible to picture. A patient calls 
upon him for relief of backache ; pelvic pains : dragging sensation 
about the loins: •* bearing-down pains :" leucorrhcea : menstrual disor- 
der, tending chiefly to excessive flow ; throbbing sensation about the 
uterus : general feeling of despondency : malaise and weakness : and 
irritability about the bladder and rectum. All these rational signs 
pointing to the uterus as the probably delinquent organ, a physical 
exploration is made, and furnishes the following results : The uterus is 
usually discovered to be in the condition of descent, retroflexion, or 
anteflexion ; it is voluminous, tender to the touch, and evidently 
engorged with blood : from the cervical canal a thick, viscid or a thin. 
vellow muco-purulent discharge pours : the probe carried to the fundus 
finds it tender and creates the flow of a little blood: the lips of the 
external os are eroded and rough, and a low grade of vaginitis exists. 

To this pathological combination the more superficial diagnostician 
will often apply a name which announces one only of the existing con- 
ditions, as, for example, uterine catarrh, ulceration of the cervix, or 



AREOLAR HYPERPLASIA, OR CHRONIC METRITIS. 307 

retroversion or prolapse. The more reflective and intelligent examiner 
will ordinarily group the coincident morbid states together under the 
name of u chronic metritis." 

The latter would be fully sustained in his position by authority as 
abundant as it is orthodox, for by systematic writers, since the days of 
Recamier, this uterine state has been described as one of " chronic 
parenchymatous metritis." Only within a recent period have the 
pathologists of the German school begun to question the validity of 
this conclusion, which, taking its origin in France, was spread through 
England and America chiefly by the writings of Dr. Henry Bennet. 
According to this view, the following pathological changes were believed 
to be those resulting in the condition just described: In the first stage 
the parenchyma was regarded as gorged with blood, a state of active 
congestion existing. This Avas supposed soon to pass into the second 
stage, consisting in an effusion of lymph, when, unlike a similar pro- 
cess in other parts, the morbid action ceased, or rather did not advance, 
and unless relieved by treatment continued stationary for a length of 
time. The third stage of inflammation in other parts — that of suppu- 
ration — was admitted to occur rarely here or in the parenchyma of the 
body, but in time, all inflammatory action ceasing, the cervix remained 
large and indurated without sensitiveness, or the effused lymph might be 
absorbed and great diminution in size occur with induration. Were 
this really the case, the condition would constitute one of inflammation, 
even if we restricted ourselves in the use of that ambiguous term to the 
narrow and precise limits prescribed by Dr. J. Hughes Bennett when 
he says : "It should be applied only to that perverted alteration of the 
vascular tissues which produces an exudation of the liquor sanguinis ; 
it is this exudation alone which can be held to unequivocally character- 
ize an inflammation." 

Examined more recently, however, by the more certain and less 
theoretical processes of modern science, all this has come to be looked 
upon as erroneous. Cases which were formerly regarded as instances 
of inflammation on account of the existence of enlargement, congestion, 
and tenderness upon pressure, the microscope now proves to have been 
instances of excessive growth of the connective tissue of the uterus, 
with congestion, and resulting hyperesthesia of its nerves. 

It may result from three entirely different pathological states : first, 
from interference with retrograde metamorphosis of the puerperal uterus 
from any cause; second, from congestion long kept up by mechanical 
causes, such as displacement; third, from a formative irritation or state 
of hypernutrition excited by endometritis or the existence of fibrous 
tumors. Whatever be the originating pathological condition, that which 
results and which we are now considering consists in hyperplasia of con- 
nective tissue as its most marked feature, and of congestion and nervous 
hyperesthesia as important accompaniments. 

It is true that some progressive writers still cling to the name chronic 
inflammation, and apply it to hyperemia resulting in hypergenests or 
hypertrophy of connective tissue, but this is by no means the signifi- 
cation which is ordinarily given to the term. Indeed, with reference 
to the uterus so vague and unsatisfactory is the appellation "chronic 



308 AREOLAR HYPERPLASIA, OR CHRONIC METRITIS. 

metritis" that there is no knowing what idea one who uses it really 
intends to convey. 

Everywhere throughout the recent and progressive literature of 
gynecology the foreshadowing of the advancing change in views with 
regard to this subject will be recognized. The pendulum, swung too far 
by the hand of Dr. Henry Bennet. is making its inevitable return. That 
it may stop on safe middle ground must be the hope of all. " The deter- 
mination of blood to a part here noticed, characterized by dilatation of 
the arteries, with increased flow of blood through the capillaries, must 
be distinguished from the congestion of inflammation, characterized bv 
the accumulation and stagnation of red and white corpuscles in the ves- 
sels, tending to be abnormally adherent to each other and to the vessels," 
says Dr. H. G. Wright, 1 quoting from Dr. Aitken. " Tested by this 
standard," says Dr. Graily Hewitt. 2 "the uterus is certainly very little 
liable to ' inflammation ;." exudations, and transformations of such exu- 
dations, purulent and otherwise, similar to what may be witnessed in 
other organs of the body, being very rarely witnessed in the paren- 
chyma of the uterus. The morbid processes with which we are familiar 
as affecting the tissues of the uterus are for the most part alterations 
of growth, irregularities in growth — slight modifications, in fact, of the 
processes which follow each other in due succession in the natural con- 
dition of things. The word ' inflammation' certainly fails to convey 
an adequate idea of the modifications observed under such circum- 
stances." "Diffuse growth of connective tissue." says Klob, 3 "con- 
stitutes the so-called induration hitherto considered as a result of 
parenchymatous inflammation of the uterus For reasons men- 
tioned I would also advise a disuse of the term ' chronic inflammation." ' 
Dr. Peaslee preferred "to call the disease under consideration conges- 
tion, rather than inflammation, because it has none of the events of 
inflammation:" and Dr. Kammerer expressed the view that "chronic 
inflammation of the substance of the non-puerperal uterus is never met 
with ; what has been described as such is hypertrophy of connective tis- 
sue resulting from long-continued hyperemia. " 

These views, which among men who are in the advance in gynecology 
are rapidly gaining ground, are not sustained by analogical reasoning, 
but by anatomical proof. We know of nothing which will more surely 
convince the reader of the necessity for an alteration in our nomen- 
clature concerning this condition than a perusal of Scanzoni's 4 article 
upon it. This author, after heading his chapter " Chronic Parenchy- 
matous Inflammation of the Womb," goes on to say: " The nature of 
the disease would then be. in an anatomical point of view, an hyper- 
trophy of the cellular tissue." Certainly the "anatomical point of 
view" is an important one. and it is supported by what we observe 
from a clinical standpoint. 

So much evil has arisen for pathology and treatment from the use of 
the term "chronic metritis," and so clear a demonstration has been 
made that the condition so called is not one of true inflammation, that 
some other appellation is not only desirable, but has become absolutely 

1 Uterine Disorders, p. 218. 2 Bis. of Women, p. 363. 

s Op. cit.. p. 129. i Bis. of Females, Am. ed.. p. 181. 



AREOLAR HYPERPLASIA, OR CHRONIC METRITIS. 309 

essential. It is incontestable that there is a peculiar condition that 
affects the uterus which is characterized by distension of blood-vessels 
from vital or mechanical cause, effusion of the serum of the blood, 
and hypergenesis of connective tissue. To denote this state gynecolo- 
gists have long required a name, for medical nomenclature is as 
necessary as it is faulty. Lisfranc felt this need when he styled it 
" engorgement ; " Hodge, when he entitled it " irritable uterus ; " Ben- 
net, when he called it "metritis; " and others also have acknowledged 
the necessity, Klob, for example, in " habitual hyperemia " and "diffuse 
proliferation of connective tissue," and Kiwisch in "infarctus." 

The appellations "infarctus," "engorgement," and "hyperemia" 
only convey a partial idea of the truth ; they only announce one ele- 
ment of the condition — congestion; while that of "irritable uterus" 
ignores all structural change in announcing another element — nervous 
hyperesthesia. At the same time that the phrase " diffuse proliferation 
of connective tissue due to hyperemia," which is employed by Klob, 
clearly defines the pathological condition, it is too long and burdensome 
to answer the purpose of a name to be conventionally employed. If 
there be a term now in existence which does really convey the idea truly 
and completely, it should surely, in the interests of pathology and 
treatment, as well as out of consideration for the overburdened student 
of medical nomenclature, be employed in preference to the adoption of 
a new one. Enlargement of an organ due to formation of new cells 
similar to those of the tissue in which they are developed has been 
styled by Virchow hyperplasia, in contradistinction to hypertrophy, 
which consists in increase of size from distension of cells already exist- 
ing. As the condition of the uterus now under consideration is one 
arising from over-excitation of the vaso-motor and excito-nutritive 
nerves, a "formative irritation," as Klob styles it, and resulting in a 
numerical hypertrophy, it appears to me that the term "areolar hyper- 
plasia" would more correctly designate it than any other with which I 
am acquainted. With a sincere desire to lessen and not to increase the 
labors of the student and the perplexities of the gynecologist, we shall 
therefore replace the confusing term "chronic metritis" by that of 
areolar hyperplasia of the uterus. 

That the term is faultless we do not claim. To one unaccustomed 
to it it must even appear peculiar. We have merely to ask for it a 
favorable consideration on the grounds that it is faithfully descriptive 
of the condition to which it is applied, and that a decided necessity for 
some such term exists. 

In a very fair critical review 1 of the third edition of this work the 
reviewer remarks that this name "involves the notion that the connec- 
tive-tissue elements alone hypertrophy, and disowns the muscular ele- 
ment as the one most readily provoked to increase. We do nor deny 
that in the disease in question there is hyperplasia of connective tissue. 
or, at any rate, of non-muscular elements ; but we must aver our belief 
that concomitantly there is increase in the muscular elements also.'* At 
first glance this appears to be a very strong point of objection : but we 
think that even the writer himself will, upon more careful examination 

1 Brit, and Foreign Medico-Chirurgical Rev.. Jan., 187i>. 



310 AREOLAE HYPERPLASIA, OR CHRONIC METRITIS. 

of the views of pathologists, agree that they look upon the proliferation 
of areolar tissue as always the characteristic or highly predominant 
feature of the condition, and regard muscular growth as an insignificant 
accompaniment only. For obvious reasons it is impossible for us to 
quote largely to sustain this position, and we confine ourselves to the 
statement of Professor Klob, 1 who in speaking of this condition expresses 
himself in the following terms : " The whole uterine connective tissue 
sometimes proliferates, either without accompanying increase of the mus- 
cular substance, or, if this does occur, the connective tissue predominates 
to such an extent that the muscular substance is comparatively of not 
much account." 

It is true that while most who have investigated this subject have 
found, like Klob and Scanzoni, a great preponderance of connective 
tissue and an insignificant increase of muscular elements, some have 
declared that the muscular structure is greatly hypertrophied. One 
reason for this variance of opinion is this : the most prolific source of 
areolar hyperplasia, the so-called chronic metritis, is interference with 
involution of the parturient uterus. What begins as subinvolution ends, 
in time, in a condition ordinarily styled chronic metritis. He who 
examines early will probably find a greater amount of muscular ele- 
ments than he who does so later ; and let it be remembered that by 
continental writers, with one exception, 2 no recognition is made of sub- 
involution as a disease distinct from what Chomel styled it, post-puer- 
peral metritis. In this way we reconcile the researches of Klob, whose 
statement we have quoted, with those of Finn, 3 who reports the follow- 
ing observations, made at the Institute of Pathological Anatomy in St. 
Petersburg : 

" 1. The normal disposition of the single muscular fibre, as well as of the 
muscular bundle, remains unchanged. 

" 2. The muscular fibres do not change in quality, neither is their fatty 
degeneration a pathognomonic sign of this disease. 

" 3. The muscular fibres are always extended in both their length and 
breadth above their normal standard, but more so in the former direction. 

" 4. The number of fibres is always largely increased. 

" 5. The amount of connective tissue in the latter stage of the disease is 
always relatively diminished, but absolutely enlarged, so that the increase 
of bulk of the uterus is mainly caused by the hyperplasia of the muscular 
fibres, the augmentation of the connective tissue influencing it but little." 

If the disease really consists in a proliferation or hypertrophy of the 
areolar or connective tissue of the uterus, and not in chronic inflamma- 
tion, it would certainly be advantageous to apply to it some name which 
would signify that fact. "Areolar hyperplasia" 4 expresses this fact 
concisely, and hence we have employed it. 

Pathology of Areolar Hyperplasia. — The vast majority of cases are 
due to interference with that retrograde metamorphosis occurring in the 

1 In the American translation of Klob the rendering is not this ; but Dr. Kammerer, 
the translator, informed us that that passage is not correct, but that this is. 

2 M. Courty. 3 Am. Journ. Obstet, vol. i. p. 264. 

4 Hypertrophy signifies excessive growth of the elements of a tissue already exist- 
ing; hyperplasia signifies the development of new tissue. 



PATHOLOGY OF AREOLAR HYPERPLASIA. 311 

puerperal uterus styled involution. To comprehend the pathology of 
cases thus arising it will be necessary to consider the physiology of that 
process as well as the pathological conditions which may affect it. 

It is only within the last quarter of a century that we have under- 
stood the process by which the uterus, an organ measuring three inches, 
in the short space of nine months enlarges so as to contain a child or 
even two or three children, and then within two months after delivery 
undergoes so rapid an absorption as to return to its original size. The 
credit of elucidating the subject belongs chiefly to Germany, for it is to 
Yirchow, Franz Kilian, Heschl, Kolliker, and Retzius that we are most 
indebted. 

The important pathological fact that arrest in or disturbance of this 
process constitutes a condition of disease emanated from Sir James 
Simpson, who in 1852 published the first article which drew especial 
attention to it. His article was entitled " Morbid Deficiency and Mor- 
bid Excess in the Involution of the Uterus after Delivery." Since that 
time the condition which now engages us has become generally recog- 
nized as a uterine state of great frequency and moment. 

To fully comprehend this part of our subject it is necessary to bear 
in mind the component parts of the healthy uterine parenchyma. It 
consists of five elements : 1st. Fusiform fibre-cells, or, as they are 
termed, the smooth muscular fibres ; 2d. Round and oval nuclei, which 
are supposed to be elementary fusiform fibre-cells ; 3d. Amorphous or 
homogeneous connective tissue, which permeates the parenchyma and 
binds together the fibre-cells and nuclei ; 4th. Fibrillated connective 
tissue or white fibrous tissue ; and 5th. Elastic fibrous tissue. These 
elements, together with nerves, blood-vessels, and lymphatics, make 
up the tissue of the uterus, which is covered by a serous membrane 
externally and a mucous membrane within. 

No sooner does this structure feel the stimulus of conception than 
it develops rapidly, partly by growth of already existing structures and 
partly by new formations. The round or oval nuclei rapidly develop 
into fusiform cells, and these as rapidly grow into colossal cells, which 
grow longer and more powerful as pregnancy advances. " A neAV for- 
mation of muscular fibre also takes place;" 1 the connective-tissue ele- 
ments grow proportionately and the blood-vessels enlarge. 

Parturition occurs, and almost immediately a retrograde evolution 
begins to restore the uterus to its original constituency. The fully- 
developed fibres undergo a fatty degeneration ; the fat thus formed is 
absorbed, and the organ rapidly diminishes in size and weight. This 
fatty degeneration affects the organ after the fourth day subsequent to 
delivery, and, according to Heschl, the commencement of a new for- 
mation of muscular fibres is recognized in the fourth week after labor, 
in the form of nuclei and caudate cells. At the end of the eighth 
week the uterus has returned to its normal state. 

Certain untoward influences may retard or check this process and 
the uterus remain flabby and large, when it is said to be in a state of 
subinvolution or arrested retrograde evolution. 

Thus far, we have been dealing witli facts thoroughly ascertained 
1 Arthur Farre, (V''- Ancit. and Plm*., article "Uterus." 



312 AREOLAE HYPERPLASIA, OR CHRONIC METRITIS. 

by histological investigations and fully established by evidence yielded 
by the microscope. But from this point the pathology of subinvolu- 
tion is not so satisfactorily settled. Prof. Simpson declared that the 
disease was due to the fact that " this retrograde metamorphosis of the 
uterus has not taken place during the puerperal month, or has taken 
place only to such an imperfect degree that the uterus is of the size 
we usually see it have at the end of the first week or so after deliv- 
ery ;" but he entered, if Ave may judge from the posthumous volume 
of his work upon Diseases of Women, upon no detailed account 
of the existing pathological defect in the organ. Since his writing 
it appears to have been agreed upon that this consists of persistence 
of the muscular fibres characterizing pregnancy in a state of fatty 
degeneration. Thus Dr. Wright 1 says: ''Pathologically, it closely 
corresponds with that state of the heart-structure so admirably 
described by Dr. Richard Quain, and commonly known as fatty degen- 
eration." Dr. West 2 expresses himself thus : "Though fatty degen- 
eration of the tissues takes place, yet the removal of the useless mate- 
rial is but imperfectly accomplished, while the elements of the new 
uterus are themselves, as soon as produced, subjected to the same alter- 
ation." We search in vain the literature of the pathology of this sub- 
ject for a basis for these hypotheses. That literature is scanty in the 
extreme as yet, and the subject awaits extended researches before we 
can speak intelligently of it. The day has passed, however, when we 
can let probabilities in pathology pass current for facts. 

The best, indeed we may say the only, detailed account of this con- 
dition studied by the microscope which we have been able to obtain is 
one by Dr. Snow Beck 3 of London : " The enlargement of the uterus 
did not depend so much upon an increase in the size of the contractile 
fibre-cells as upon an increased amount of round and oval globules, 
with amorphous tissue in the uterine walls The essential con- 
dition of the organ consisted in the elements of the different tissues 
retaining a portion of the natural enlargement consequent upon impreg- 
nation. But this enlargement was more due to the increased size and 
amount of the soft tissue present in the w T alls of the uterus, as well as 
at the internal surface, than to the increased size of the contractile 
fibre-cells." Marked congestion existed, the blood-vessels being large 
and forming a complete and continuous system with the capillary net- 
work on the inner surface of the uterus. No allusion to preponderance 
of muscular fibres is anywhere made, and no mention of fatty degene- 
ration occurs. 

The condition of the uterine cavity is important. It is always 
increased in size, the glands of the cervix are usually enlarged, and 
upon the lining membrane of the cavity fungoid growths are commonly 
developed. 

This is all that can w T ith positiveness be said of the pathology of 
the early periods of subinvolution in the present undeveloped state of 
the subject. 

The uterus, the study of the tissues of which gave Dr. Beck's results, 

1 Uterine Disorders, p. 221. 2 Bis. of Women, 3d Eng. ed., p. 89. 

3 London Obstetrical Trans., vol. xiii. p. 239. 



PATHOLOGY OF AREOLAR HYPERPLASIA. 313 

measured 3J inches in length, 2^ inches across the fundus, the walls 
were If inches thick, and the uterine canal was 3 inches deep. 

As time passes the uterine walls diminish in size, their tissue grows 
less vascular, the blood-vessels become smaller, and the uterine cavity 
assumes smaller dimensions. But the organ does not assume its origi- 
nal size: it remains large, dense, firm, and sensitive, for years present- 
ing the characteristic appearances of the so-called chronic parenchyma- 
tous metritis. Although taking an entirely different view of the 
pathology of chronic metritis, Dr. West 1 signalizes almost the same 
fact in the following words : " It must, however, be at once apparent 
that after inflammation has passed away its effects may remain in the 
larger size and altered structure of the womb, and that the very nature 
of these changes will be such as to render the repair of the damaged 
organ both unlikely to occur and slow to be accomplished, and must 
leave it in a condition peculiarly liable to be aggravated during the 
fluctuation of circulation and alternations of activity and repose to 
which the female sexual system is liable." This is just the state to 
which we alluded at the commencement of this chapter as one existing 
years after labor, and which, attended by congestion, displacement, 
catarrh, and granular degeneration, is styled chronic metritis. It is, 
we think, this state which most frequently furnishes instances of areo- 
lar hyperplasia to the microscope. 

Let any one faithfully and patiently watch a case of subinvolution 
for a year or two with reference to this point, as we have repeatedly 
done, and we cannot doubt that he will have the same evidence which 
makes us so strong in our present belief. Lastly, let it be remembered 
that by the French school no condition of arrest of development is recog- 
nized as accounting for it; these are cases of "post-puerperal metri- 
tis " — metritis, according to M. Gallard, 2 without symptoms, " chronique 
d'emblee." 

Does any one claim that between this condition and chronic metritis 
a difference should be made ? Let him tell me by what means he can 
at the bedside distinguish one from the other, and I may agree with 
him. There are no means for such differentiation. If the uterus be 
very large and the patient recently delivered, the case is termed sub- 
involution by English writers ; if its dimensions have diminished, years 
have elapsed since parturition, and the almost universal accompaniments 
of the condition, leucorrhoea, granular degeneration, and displacement, 
be present, it is styled chronic metritis. 

Arrest of involution of the puerperal uterus is an occurrence of 
very great frequency. It constitutes the chief cause of all chronic 
uterine disorders, and for this reason its importance cannot be over- 
estimated. Until this subject receives the attention which it deserves, 
the present confusion as to the causes, pathology, and general features 
of chronic metritis, which helps to weaken uterine pathology, must 
continue. 

As a very general rule, areolar hyperplasia, the so-called chronic 
metritis, is a consequence of subinvolution. This constitutes the 
explanation of the fact that so large a number of women with uterine 

1 Op. cit., p. 89. - Op. ciV., p. 372, 



314 AREOLAR HYPERPLASIA, OR CHRONIC METRITIS. 

affections refer their illness to child-bearing, and that so many who are 
well until that process remain invalids afterward. Go back to the com- 
mencement of all cases of uterine disease, and a very large proportion 
will date from parturition. These hyperplastic or subinvoluted uteri 
were those which chiefly furnished Lisfranc's cases of '■ engorgement," 
which Jobert " melted down " with the actual cautery, and which hun- 
dreds to-day are treating by powerful caustics as parenchymatous 
metritis. The question may be asked, Do we ourselves not blister, 
apply leeches, and even amputate the cervix in these cases? The ele- 
ment which sustains the disease is an excessive supply of blood ; to 
diminish this is to strike at the root of the evil. In areolar hyperplasia 
we blister lightly, to exert an alterative influence upon the nerves ; 
for the relief of coincident congestion we leech occasionally, as we 
would for hyperemia elsewhere ; and we amputate, as we would do the 
enlarged tonsils ; but nowhere would we treat the condition as inflam- 
mation. 

Compared with interference with involution, all other pathological 
influences become comparatively insignificant as causes of this condi- 
tion ; nevertheless, they must receive due weight. The tissue of the 
virgin uterus presents a structure unfavorable to this disorder. That of 
a uterus once affected by gestation offers a more propitious field for its 
development. 

Displacement of the uterus at first results in passive congestion ; this 
being kept up, hypergenesis of connective tissue takes place. Fibroids, 
whether they be submucous, subserous, or mural, keep up a constant 
nervous irritation that induces hyperemia, which proves the first step 
toward this affection. In a very important essay Rouget 1 proves the 
uterus to be an erectile organ, as richly supplied with a network of ves- 
sels as such organs always are, and very subject to active physiological 
congestion. It is certain that such a kind of hyperemia attends ovula- 
tion, and it is highly probable that sexual congress has a similar result. 
From this it will appear how prolongation of the moUmen menstruationis 
and excessive indulgence in sexual intercourse, especially near menstrual 
epochs, may produce evil consequences. 2 

As cardiac diseases and abdominal tumors, which interfere with 
venous return through the vena cava, produce blood-stasis and oedema 
of the feet, of the labia majora, and of the parts about the vagina, so 
do they result in the same way in the uterus. Klob declares that this 
purely passive congestion is capable of inducing hypernutrition and 
hypertrophy of the connective tissue. 3 

It has been already said that in acute endometritis the hyperemia 
attending the disease ordinarily extends to the parenchymatous layers 
immediately adjacent to the diseased mucous membrane, and that in 
chronic endometritis there is often in the submucous connective tissue 
an absolute hypertrophy. In some cases the process passes into a dif- 
fuse proliferation of the connective tissue of the entire uterine wall. 
Thus as a result of cervical endometritis we sometimes find cervical 

1 Rouget, Recherches sur les Organes erectiles de la Eemme. 

2 Scanzoni calls attention to the fact that it is met with in prostitutes. 

3 Klob, op.cit., p. 130. 



PATHOLOGY OF AREOLAR HYPERPLASIA. 315 

hyperplasia resulting, and so with the disease in the cavity of the body. 
As we have already stated, where the uterine parenchyma has never 
undergone the physiological hypertrophy and retrograde metamorphosis 
attendant upon utero-gestation, endometritis will continue for a long 
period without exciting hyperplasia ; but where such changes have 
occurred the more loose and permeable texture offers itself as an easier 
prey to the morbid process. Thus cervical endometritis will continue 
for years in the virgin without any apparent enlargement of the struc- 
ture of the neck, while such a result soon follows in a woman who has 
borne children. This fact formerly did not attract special attention, 
and yet it is a point which every practitioner must recognize when it is 
brought to his attention as one which is familiar. The reason for this 
difference is that during childbirth the cervix is very frequently torn 
or bruised, and in consequence cervical subinvolution, hyperplasia, and 
endometritis result. Parturition has been the predisposing cause, injury 
of the cervix the exciting. 

A very striking illustration of this affection due to non-puerperal causes 
is related by Dr. West, whose observation seems to have led him to very 
similar conclusions with mine. " Some years ago," says he, " I saw a 
lady, aged forty-three, who during thirteen years of married life had 
never been pregnant. She had always menstruated painfully and 
rather profusely, and both these ailments had by degrees grown worse, 
and this especially during the last few months. She complained of a 
sense of weight and dragging immediately on making any attempt to 

walk, and induced even by remaining long in the sitting posture 

Menstruation was very profuse, accompanied by discharge of coagula, 
while at uncertain intervals during its continuance most violent parox- 
ysms of uterine pain came on. On examination the enlarged uterus 
was distinctly felt above the symphysis pubis, as large as the doubled 
fist, and per vaginam the whole organ was found much enlarged and 
much heavier than natural ; the cervix large and thick, but not indu- 
rated; the os uteri small and circular; and the hymen was entire." 1 
He goes on to say : " Whenever the uterus is exposed to unusual irri- 
tation it increases in size ; not necessarily nor, I believe, generally as the 
result of inflammation, but because the organ is composed of formative 
material which excitement of any kind will call into active develop- 
ment." 

In the first stage of the disease the hypertrophied areolar tissue is 
congested, containing absolutely more blood than normal, and the whole 
of the affected part, neck, body, or entire uterus, is greatly increased 
in size and weight. As time passes the second stage of the disorder 
supervenes, and an opposite state of things is set up. Klob describes 
it in these words : tk The parenchyma on section appears white or of a 
whitish-red color, deficient in blood-vessels from compression of the 
capillaries by the contraction of the newly-formed connective tissue 
or from partial destruction or obliteration of vessels during the growth 
of tissue; the firmness of the uterine substance is also increased, simu- 

1 [This case, with due deference to Dr. AVest and the author, would to me seem to 
illustrate far more probably and graphically the development of an interstitial fibroid 
in the uterus.— P. V. M.] 



316 AREOLAR HYPERPLASIA, OR CHRONIC METRITIS. 

lating the hardness of cartilage, and creaking under the knife. This 
constitutes a true sclerosis 1 of the uterus. 

Every practitioner must have met with cases in "which a large, red, 
engorged, and soft uterus, examined after an interval of several years, 
has been found, to his surprise, to have become small, densely hard, 
white, and anaemic, and its cavity diminished in size. Such an organ 
removed from the body cuts like fibrous tissue, and appears when cut 
almost as dense and bloodless. 

In leaving this important and interesting part of my subject let us 
sum up in a few words what has been said : 

1st. The condition ordinarily styled chronic metritis consists in an 
enlargement due to hypergenesis of its tissues, especially of its connec- 
tive tissue, which induces nervous irritability and is accompanied by 
congestion. 

2d. Decidedly the most frequent source of this state is interference 
with involution of the puerperal uterus. A very large proportion of the 
cases of so-called chronic parenchymatous metritis are really later stages 
of subinvolution. 

3d. Areolar hyperplasia is often induced in a uterus which has once 
undergone the development of pregnancy, by displacement, endometri- 
tis, and other conditions inducing persistent hyperemia. 

4th. The same influences may possibly produce it in the nulliparous 
uterus ; most frequently they do so in the neck, but such a result is 
exceedingly infrequent. 

5th. However produced, the condition is one of vice of nutrition, 
engendering hyperplasia of connective tissue as its most striking fea- 
ture, and, although attended by many of the signs and symptoms of 
inflammation, it in no way partakes of the character of that process. 

It has been maintained by some that acute puerperal metritis extends 
itself into the chronic metritis of the non-puerperal state, and this form 
of the affection has been differentiated from subinvolution. We have 
seen no evidence of the correctness of this view, nor do we believe that 
any such distinction can be made at the bedside. 

Course and Termination. — The length of time which this condition 
may last is very uncertain. After the connective tissue once becomes 
thoroughly affected by the disease it rarely returns to its original con- 
dition, but so complete is the relief which may be afforded the patient 
by removal of those concomitant conditions that attend upon it and 
increase the discomforts which are due to it, that she will often for 
years imagine herself well. Very suddenly, however, imprudence dur- 
ing menstruation, the act of parturition, over-exertion, or some other 
influence creating congestion will produce a relapse which will convince 
her of her error. It is astonishing to what an extent enlargement of 
the cervix as a result of areolar hyperplasia will go. Sometimes this 
part will equal in size a very small orange, and, filling the vagina, will 
compress the rectum to such an extent as to interfere with its functions. 
Uninterfered with by art, the disease has no fixed limits. The increase 
of uterine weight which it induces usually results in displacement. This 

1 The term "sclerosis" was, I believe, first applied to this condition by Skene of 
Brooklyn. 



VARIETIES— FREQ UENCY. 



317 



increases already existing congestion, and the patient suffers, until the 
menopause at least, from endometritis, granular cervix, and the ordinary 
symptoms of displacement. 

In some cases contraction of the exuberant tissue occurs, and ute- 
rine atrophy with its accompanying symptoms takes place. 

Varieties. — Whatever be its cause, areolar hyperplasia may affect 



Fig. 146. 



Fig. 147 





Cervical Hyperplasia (Diagrammatic). 



Corporeal Hyperplasia (Diagrammatic), 



the entire uterus ; it may limit itself to the neck, extending from the 
os externum to the os internum, or it may affect the body from the os 
internum to the fundus. The habitat of hyperplasia limited to the 
cervix is represented by Fig. 146, while Fig. 147 represents that of 
the corporeal variety. 

Hyperplasia of the body of the uterus only is not at all common, 
either from imperfect involution or from non-puerperal causes. When 
it apparently does occur, the examiner should pay special attention to 
the possibility that it may be simulated by the development of intra- 
mural growths, usually of a fibrous or muscular character, or that malig- 
nant disease of the corpus uteri may be present. 

When the cervix alone is hyperplastic the cause may generally be 
sought in the irritation produced by a lacerated cervix. This accident. 
as will be treated at length later on, is very common ; hence cervical 
hyperplasia is by far more frequent than the corporeal variety. Occa- 
sionally the enlargement may be so marked that suspicion of its being 
due to malignant disease is well, justified — -a question which usually the 
microscope alone can definitely settle. The clinical history and special 
symptoms should, of course, be carefully weighed before deciding, since 
even the microscope may at times fail us. 

Frequency. — This affection is one of great frequency, and as it was 
formerly universally regarded as chronic parenchymatous metritis, this 
is one ereat reason why inflammation of the structure of the uterus was 



318 AREOLAR HYPERPLASIA, OR CHRONIC METRITIS. 

of great moment to the gynecologist. We do not hesitate to declare 
that he who fully masters it and thoroughly appreciates its frequency 
and influence will possess a key to the management of numerous cases 
which would in vain be sought for elsewhere. 

As we have before remarked, interference with that retrograde 
metamorphosis of the puerperal uterus which is now styled involution is 
in the great majority of cases its cause. For this reason, as above 
remarked, the cervical variety is the most frequent. The reason for 
this is to be found in the facts that the cervix is peculiarly exposed to 
mechanical injury from coition, friction against the vaginal walls, and 
laceration occurring during parturient distension ; that after child- 
bearing the connective tissue at this point is looser and more permeable 
than that of the body ; and that when involution is retarded for some 
months, and then is accomplished, it usually takes place in the body, 
but fails to do so in the neck, from that exposure to injurious influences 
which has just been alluded to. 

The body of the uterus is so completely removed from contact with 
mechanical agencies outside of the abdomen that this part of the organ, 
as already stated, is not so frequently affected by hyperplasia as the 
corresponding tissue of the cervix. Still, it is by no means unfre- 
quently diseased. A large number of cases of obstinate uterine dis- 
orders occurring as a remote result of parturition are really of this 
nature, and the displacements, rebellious leucorrhcea, and other con- 
comitant evils which characterize them are merely symptoms of this 
affection or of some of its resulting complications. An important fact 
connected with this state is that where hypertrophy of the connective 
tissue exists transient attacks of active congestion frequently occur and 
excite acute symptoms. These pass away, leaving the basis of the 
affection in its original state, again to return with all the signs of relapse. 
And thus a series of short but severe exacerbations go on developing 
themselves in the ordinary course of an attack of the disorder. 
Predisposing Causes. — These may be enumerated as — 

A depreciation of the vital forces from any cause ; 

Constitutional tendency to malnutrition or spansemia ; 

Parturition, especially when repeated often and with short 
intervals ; 

Prolonged nervous depression ; 

A torpid condition of the intestines and liver. 
Nulliparity secures, to a very great extent, an immunity from the 
disease, and multiparity constitutes a most important predisposing 
cause. This fact arises not merely from its being, as it often is, an 
immediate consequence of the parturient act, but from the peculiar 
tissue-changes of utero-gestation rendering the uterus prone to its 
development. " Frequently," says Klob, "this proliferation of con- 
nective tissue is developed after repeated deliveries in rapid succession 
without any previous or existing inflammation." .... Its "causes 
must be sought for in habitual hyperemia;" consequently, whatever 
state gives a tendency to this must be regarded as a predisposing cause, 
while one which induces and perpetuates it must be looked upon as 
exciting. The woman who has never been pregnant is much less liable 



SYMPTOMS. 319 

to areolar hyperplasia than she whose uterus has undergone the tissue- 
changes of utero-gestation. Nevertheless, in very rare and exceptional 
cases we think that she may suffer from it. In the whole of our expe- 
rience we have seen but two or three cases, and the diagnosis in these 
is based upon clinical evidence alone. 

Here let us guard the reader against a fallacious argument which is 
often used in reference to this matter. As areolar hyperplasia is rarely 
seen except in women who have borne children, it is said that it is 
always the result of interference with involution. This is incorrect, A 
woman bears a child, has no post-partum trouble, and goes through 
uterine involution perfectly. A year or two afterward she has endome- 
tritis. This in time produces areolar hyperplasia with its usual symp- 
toms and physical signs. The same kind and degree of endometritis in 
a nulliparous woman would have lasted for years without parenchymatous 
complication. In the former case the endometric disease existed on 
ground favorable to hyperplasia, because an important predisposing 
cause existed. In the latter such predisposition was wanting. 
The exciting causes are the following : 

Over-exertion after delivery ; 

Puerperal pelvic inflammation ; 

Laceration of the cervix uteri ; 

Displacements ; 

Endometritis ; 

Neoplasms ; 

Cardiac disease ; 

Abdominal tumors pressing on the vena cava ; 

Excessive sexual intercourse. 
After delivery many of both these sets of causes are developed by 
the pernicious system of management which nurses frequently adopt. 
The nerve- and blood-states of the woman are depreciated by starvation, 
impure air, and disturbance of sleep by attention to the wants of a child, 
while the enlarged uterus is forced into retroversion and the congestion 
which it induces by a very tight bandage, rendered still more hurtful 
by a thick compress over the uterus. The practitioner who regards 
delivery of the placenta as the end of the third stage of labor fur- 
nishes a marked predisposing cause. The third stage of labor consists 
in complete and permanent contraction of the uterus, and may not be 
accomplished for hours after the expulsion of the placenta, No obste- 
trician has done his duty who leaves his patient before its accomplish- 
ment. 

Symptoms. — It is impossible to present the symptoms of this con- 
dition entirely separated from those of complications which very com- 
monly attend it, such, for example, as displacement, laceration of the 
cervix, ovarian congestion, chronic endometritis, etc. These states of 
course produce symptoms of their own which mingle with those of the 
main disorder. Practically, they are identical with those produced by 
extensive laceration of the cervix and its complications. If the cervix 
alone be affected, they are — 

Pain in back and loins; 

Pressure on bladder or rectum ; 



320 AREOLAE HYPERPLASIA, OR CHRONIC METRITIS. 

Disordered menstruation ; 

Difficulty of locomotion ; 

Nervous disorder ; 

Pain on sexual intercourse ; 

Dyspepsia, headache, and languor ; 

Leucorrhoea. 
If the affection be general or corporeal, the above symptoms are 
merely intensified in proportion to the increased size and weight of 
the uterus. 1 Chief among these are — 

A dull, heavy, dragging pain through the pelvis, much increased 
by locomotion ; 

Pain on defecation and coition ; 

Dull pain, beginning several days before menstruation and 
lasting during that process ; 

Pain in the mammae before and during menstruation ; 

Darkening of the areolae of the breasts ; 

Nausea and vomiting ; 

Great nervous disturbance ; 

Pressure on the rectum, with tenesmus and hemorrhoids ; 

Pressure on the bladder, with vesical tenesmus ; 

Sterility. 
Physical Signs of Cervical Hyperplasia. — Vaginal touch will gene- 
rally discover that the uterus has descended in the pelvis, so that the 
cervix will rest upon its floor. The cervix will be found to be large, 
swollen, and painful, and the os may admit the tip of the finger. If 
the finger be placed under the cervix and it be lifted up, pain will 
usually be complained of, and if it be introduced into the rectum, so 
as to press upon the cervix as high as the os internum, it will often 
reveal a great degree of sensitiveness. Under these circumstances the 
direction of the uterine axis will generally be found to be abnormal. 
The cervix will in some cases have moved forward and the body back- 
ward, or the opposite change of place may have occurred. 

Physical Signs of Corporeal Hyperplasia. — If two fingers be car- 
ried into the vagina and placed in front of the cervix, so as to lift the 
bladder and press against the uterus, while the tips of the fingers of the 
other hand be made to depress the abdominal walls, the body of the 
uterus will, unless the woman be very fat, be distinctly felt should the 
organ be anteflexed. Should it not be detected, let the two fingers in 
the vagina be now carried behind the cervix into the fornix vaginae, 
and the effort repeated ; if the uterus be retroflexed or retroverted, or 
even in its normal place, it will be detected at once. By these means 
we may not only learn the size and shape of the organ, but its degree 
of sensitiveness. This may likewise be accomplished to a certain extent 
by rectal touch. The uterine probe may then be introduced, the cavity 
measured, and the sensitiveness of the walls carefully ascertained. 

A point which should be settled before the diagnosis can be consid- 
ered complete will be whether the cervix alone is affected or whether its 
enlargement is only a part of a general uterine development. To deter- 

1 It must not be supposed that all these symptoms occur in all or even in the major- 
ity of cases. In many cases few, and in some almost none of them, will be recognized. 



DIFFERENTIA TION. 321 

mine this question two means are at command : first, the examiner, 
introducing one or two fingers under the body of the uterus, and depress- 
ing the abdominal walls by the other hand, so as to clasp the fundus, 
ascertains whether it is larger than it should be or of normal size and 
free from sensitiveness. He then passes the uterine probe into the cav- 
ity of the body and measures it. If the uterine cavity be increased 
in size, the evidence is in favor of the disease having extended to the 
tissue of the body. Should its size be normal, this is probably 
not the case. Still, in a large proportion of cases of general hyper- 
plasia the length of the uterus is not increased, and the sound en- 
ters only the normal two and a half inches ; but on bimanual pal- 
pation the body is felt to be decidedly thickened in the antero-posterior 
diameter. 

Differentiation. — When the whole uterus is affected or the body of 
the organ alone is enlarged, the diseases with which areolar hyperplasia 
may be confounded in its first stage are — 

Subinvolution ; 

Pregnancy ; 

Neoplasms. 
From these a careful differentiation should be made, for if in error the 
practitioner would not only fail in giving relief, but in some cases might 
do great injury. For example, an examination by the probe might 
produce abortion and cause serious and alarming consequences. The 
introduction of the probe or sound should, for this reason, be practised 
with great caution, and only when good reason exists for supposing 
pregnancy absent. 

Between pregnancy and endometritis with corporeal hyperplasia 
there is a chance of error in diagnosis, for in both there are enlarge- 
ment of the breasts, darkening of the areolae, enlargement of the uterus, 
derangement of the nervous system, and nausea and vomiting. In the 
one, however, menstruation does not cease, there is no kiesteine in the 
urine, there is great sensitiveness of the body of the uterus, and an 
abundant leucorrhcea. 

Fibrous growths in the uterine walls will sometimes, from the pecu- 
liar symmetry of their development, completely mislead us, giving ute- 
rine enlargement, leucorrhcea of bloody character, etc. We have now 
in our possession a uterus in the anterior wall of which a fibrous tumor, 
equal in size to a goose's egg, gives upon superficial examination all the 
appearances of engorgement and hypertrophy of uterine tissue with 
anteflexion and endometritis. In the same manner polypoid growths 
or submucous fibroids might snve trouble in diagnosis. Under such 
circumstances reliance would have to be placed upon the use of the 
sound, conjoined manipulation, and tents, together with the rational 
signs. 

Sometimes, suspicion of scirrhous cancer in an early period being 
entertained, it becomes necessary to decide between its existence and 
that of the second stage of areolar hyperplasia or sclerosis. Scanzoni 
doubts the possibility of deciding, but it appears to me that the inves- 
tigator will usually succeed in doing so by the following comparison ot' 
signs and symptoms : 

2i 



322 AREOLAR HYPERPLASIA, OR CHRONIC METRITIS. 

In Cervical Sclerosis — In Scirrhous Cancer — 

The patient shows no cachexia. She often does. 

There is tendency to amenorrhea. There is tendency to hemorrhage. 

The history usually points to parturition. It does not. 

It has been preceded by symptoms of uterine It has not. 

enlargement. 

The cervix feels like dense fibrous tissue. It feels almost like cartilage. 

The body is perhaps implicated. It is rarely so. 

A sponge-tent softens the tissue. 1 It leaves it hard and dense. 

Prognosis. — The prognosis in hyperplasia of the entire uterus or 
of the body alone is unfavorable with regard to complete cure, though 
highly favorable with reference to great relief of symptoms and to dan- 
ger to life. Should the patient be approaching the menopause, it is 
possible that after the functions of the uterus cease atrophy may occur 
and relief be obtained. But one cannot be sure even of this, for the 
monthly discharge may give place to metrorrhagia or all the symptoms 
may continue in spite of the menstrual cessation. Under a course of 
local treatment, combined with one conducted with special reference to 
the general system, hope may always be held out that although resto- 
ration of the uterus to its normal condition may not be effected, the 
evils resulting from the complications of this disease can be so fully 
controlled that comfort will be obtained. When the neck of the uterus 
alone is aifected, a favorable prognosis may always be made, for here 
there are fewer grave complications to be encountered, such, for exam- 
ple, as corporeal endometritis, menorrhagia, etc. The diseased part is 
likewise more accessible to local treatment, and is also a much less sen- 
sitive and important part of the organism ; we might indeed almost 
say a less important organ, so distinct are the uterine body and neck 
physiologically and pathologically. As we have elsewhere stated, the 
prognosis will depend in a great degree upon the patient. If she be 
unwilling to sacrifice her inclinations and pleasures, but half fulfil the 
directions of the attending physician, and clandestinely expose herself 
to prejudicial influences, the treatment will accomplish nothing. In 
the case of a reasonable patient, who appreciates what is at stake and 
is anxious to regain her health, it may be regarded as favorable. 

Complications. — Areolar hyperplasia may give rise to many and 
serious complications, as, for example, displacements, cystitis, rectitis, 
cellulitis, endometritis, menstrual disorders, hysteria, dyspepsia, ovarian 
disorders, etc. 

Although it has been suggested that general areolar hyperplasia may 
have a causative influence on the production of uterine carcinoma, there 
is no valid reason to fear such a result, at least so far as the body of 
the organ is concerned. That a hyperplastic cervix, especially if the 
enlargement is due to laceration, may not eventually undergo malignant 
degeneration, we are not, however, prepared to deny. 

Treatment. — Let us urge upon the practitioner, as a rule to be 
observed in every case before treatment is adopted for this disorder, to 
examine for and remove, if discovered, the four following complications, 
which very often accompany areolar hyperplasia and establish symptoms 

1 This test originated with Spiegelberg. 



treatment: 323 

which greatly increase the evils attending it. So important do we con- 
sider them that we give them decided prominence : 

1st. Laceration of the cervix uteri, which creates intense nervous 
irritation, both immediate and reflex, and consequent uterine congestion 
and neuralgia ; 

2d. Displacement of the uterus, which results in vascular engorge- 
ment, dragging upon uterine ligaments, mechanical interference with 
surrounding parts, and difficulty in locomotion ; 

3d. Fungoid degeneration of the endometrium, which results in pro- 
fuse leucorrhoeal and bloody discharges ; 

4th. Granular and cystic degeneration of the cervix, which produces 
nervous and vascular derangement of the uterus, leucorrhcea, and 
monorrhagia, and is generally due to laceration, or, if in the nullipara, 
to chronic endometritis. 

He will be most successful in the treatment of areolar hyperplasia 
who most assiduously searches for and cures these complicating condi- 
tions before addressing remedies to the main affection. 

Laceration of the cervix and exposure of the delicate walls of the 
cervical canal to friction against the vagina are so frequently not only 
a concomitant circumstance, but, we think, a cause of this condition by 
interfering with involution, that they should always be looked for. Let 
it not be supposed that a mere visual inspection will reveal their exist- 
ence. It will often fail to do so, while the red and excoriated cervical 
Avails are being for long periods treated for so-called ulceration by caus- 
tics and alteratives. To test the question, a tenaculum should be fixed 
in each labium cervicis, and the lips should be approximated so as to 
present to the eyes of the examiner the perfect cervix as it existed 
before the accident. Once discovered, the inner surfaces of the torn 
lips should be thoroughly pared and brought together by suture. Such 
an operation will often have a most happy effect upon the uterine dis- 
order ; nervous irritability will disappear and nutrition become greatly 
improved by removal of this focus of irritation. 

If displacement exist, great benefit will be obtained from support 
rendered by means of a light and well-fitting pessary — the elastic ring 
of Meigs if there be merely direct descent ; Hodge's double lever or 
one of its varieties if there be retroversion ; or an anteversion pessary 
if the uterus have fallen forward. In some cases the benefit derived 
from these instruments will be the chief, perhaps the only, relief which 
we can bestow, and even where we cannot cure the disease we may by 
their use render life much more agreeable by the alleviation of dis- 
comfort. 

If evidences of fungoid growths on the endometrium exist, the 
whole cavity should be gently scraped by the wire-loop curette, and this 
source of leucorrhcea, metrorrhagia, and uterine congestion taken away; 

At the same time that Ave have elseAvhere urged that too great import- 
ance should not be given to granular and cystic degeneration of the 
cervix, Ave Avould not ignore the fact that, once established, they 
become a source of irritation, and thus of uterine engorgement. They 
should by all means be treated and removed. 

Vaginitis is secondary to uterine catarrh, which is a very common 



324 AREOLAR HYPERPLASIA, OR CHRONIC METRITIS. 

accompaniment of hyperplasia. It should be treated by the ordinary 
means elsewhere indicated, and a recurrence prevented by relief of the 
endometrial disease. 

The subject carefully analyzed presents itself in this way : If the 
abnormal condition which has created areolar hyperplasia has passed 
away, this condition is not in itself the source of many disagreeable 
symptoms. No woman thus affected feels perfectly well, but she is 
often sufficiently comfortable to be able to perform all her duties in life. 
But the uterus thus diseased is peculiarly liable to certain complicating 
conditions which have just been mentioned, and these create a great 
deal of discomfort by production of pains in the back and loins, ner- 
vousness, leucorrhoea, and menstrual disorders. These symptoms are 
then in a great degree, as we stated in giving the symptomatology of 
hyperplasia, due to the complications of the disorder, and not to the 
disorder itself. In other words, sustain a hyperplastic uterus, keep it 
free from displacement, granular and cystic disease of the cervix, and 
uterine catarrh, and the patient will be so comfortable as in most 
instances to feel satisfied with her condition. Sometimes this is all that 
we can accomplish. The mere fact of accomplishing these results will, 
however, do much for the cure of the disease itself. Relief of dis- 
placement favors free venous return and prevents congestion, which feeds 
and perpetuates hyperplasia. Cure of uterine catarrh and of granular 
and cystic degeneration of the cervix removes two great causes for 
hyperemia of mucous and submucous tissues. The means employed foi 
the relief of these symptoms even do more: they tend by their own 
direct influence to alter the morbid state of the nerves of the part, to 
diminish the calibre of blood-vessels under their control, and thus to 
check excessive nutrition and secretion. 

All complications being removed, the practitioner has now to deal 
with a large, heavy uterus, the tissue of which is exuberant, the blood- 
vessels enlarged, and the nerves in a condition of hyperesthesia. 

Let us enumerate the indications to be met by a few leading propo- 
sitions : 

1st. Everything possible should be done to prevent congestion, and 
remove that already existing ; 

2d. Every attention should be given to the restoration of the gen- 
eral system, especially the blood- and nerve-states ; 

3d. All weight should be taken from the large and heavy uterus ; 

4th. Nervous hyperesthesia should be relieved by every means in 
our power. 

The means for furthering these ends may thus.be presented: 
Rest ; 

General treatment ; 
Depletion ; 

Emollient vaginal injections; 
Alteratives. 

Rest. — The patient should be instructed to take much less exercise 
than usual, to lie upon her bed or lounge for an hour every day about 
mid-day, and to be especially quiet during menstrual periods. It is, as 
a general rule, highly improper to confine her to bed, for many women 



REST. 325 

become restive under the confinement and suffer both in mind and body, 
the sanguineous and nervous systems being impaired by want of fresh 
air. If the connective tissue be so much affected that the cervix is 
very painful upon pressure, absolute rest upon the back may become 
necessary, but our impression is that deprivation of fresh air and exer- 
cise ordinarily does more harm than is compensated for by the advan- 
tages arising from quietude. Every day she should go, unless deterred 
by some special cause, into the open air, and a limited amount of exer- 
cise should be inculcated as a means of keeping up the general health. 

Dr. Weir Mitchell has introduced a now well-tried and universally 
known plan for treating cases of neurasthenia, which consists of com- 
plete rest. The patient is for a period varying from six weeks to three 
months kept as quiet, upon her back in bed, as if she were a marble 
statue ; or rather, we should say, as far as voluntary motion is con- 
cerned. She is fed by an attendant, who is constantly by her side, 
and is not allowed even to lift her arms from the bed. Meantime she 
is very thoroughly nourished by milk, animal broths, malt, cod-liver 
oil, eggs, and other nutritious substances every two or three hours, 
while cutaneous action is excited, peripheral circulation kept at a maxi- 
mum of activity, metamorphosis and elimination are increased, and 
muscular strength is fostered, by manipulation, passive exercise, elec- 
tricity, and kneading. The moral faculties are likewise supervised ; 
hysterical symptoms are controlled by moral suasion, judicious neglect, 
and an earnest appeal to the reason of the patient ; and the mind is 
made to feel the influence of alienation from home influences by entire 
seclusion from friends and relatives. 

We can of course only allude to this plan, which observation leads 
us to set a very high estimate upon in the treatment of special cases, 
and would refer the reader for further details concerning it to the 
writings of Dr. Mitchell l and to an excellent article by Dr. William 
Goodell. 2 

The uterus should be placed at rest as much as possible. Its nat- 
ural tendency under these circumstances is to fall from its position ; 
consequently, all pressure should be removed from its fundus by wear- 
ing the clothing loose, sustaining the weight of the skirts by attaching 
them to the upper garments, so as to have the shoulders bear the bur- 
den, and uncompromisingly abolishing the corset. 

At the same time a system of exercises should be practised by the 
patient calculated to develop the power of the abdominal and thoracic 
muscles, and thus restore or increase the retentive power of the abdo- 
men. These will be alluded to in detail under the head of Displace- 
ments of the Uterus. 

Abdominal bandages are very unpopular with many practitioners, 
who believe that they absolutely do harm. We believe otherwise, and 
regard them as great adjuvants, not in keeping up the uterus, but in 
supporting the superimposed viscera, which, pressed downward by tight 
clothing and badly supported on account of the relaxation of the 
abdominal walls, fall directly upon the fundus. There is a great 

1 Fat and Blood, and Ihnv to Make them. 

2 "Nerve-tire and Womb-ills," Lesson* in Gynecology. 



326 AREOLAR HYPERPLASIA, OR CHRONIC METRITIS. 

variety of abdominal supporters. We have no favorite, for one will 
accomplish the end in a woman of a certain figure which would be 
inappropriate for another. That one should be selected which abso- 
lutely accomplishes the end in view — namely, sustaining the viscera 
and supplementing the weakened muscles of the abdomen. 

Sexual intercourse often produces bad results in an organ which is 
so prone to congestion, and great infrequency and caution should be 
enjoined with reference to it. 

By combining all these means we do all in our power to place the 
hyperplastic uterus at rest, as we would a fractured bone or enlarged 
testicle. 

General Treatment. — The diet should be plain and unstimulating, 
but at the same time nutritious and in every way calculated to maintain 
the normal state of the blood. Should spansemia exist, ferruginous 
tonics, alone or combined with vegetable tonics, should be administered. 
The bowels should be kept in a perfectly normal state and the skin 
active. Specific remedies have been, and are still, employed by some 
practitioners for diminishing the size of the uterus. Of most of these 
we doubt the efficacy. During the state of enlargement — that is, before 
contraction of the exuberant tissue has occurred — ergot, kept up for a 
considerable time, produces good results. By its power of exciting 
contraction of the uterine tissue it diminishes hyperemia and lessens 
the bulk of the uterus. 

European writers speak in high terms of the alterative influences of 
the various watering-places and baths of the Continent, as those of 
Marienbad, Schwalbach, Briickenau, and Kissingen in Germany, and 
of Saint Sauveur, Barreges, etc. in France. None of these equal in 
reputation the waters of Kreuznach in Germany, the curative property 
of which depends to some extent upon the bromide of magnesium which 
they contain. It is very probable that the hygienic and social influences 
which surround these places and render them attractive are to be 
credited with most of the good that they do. The peat- or "moor"- 
baths, now so commonly used at Franzensbad, Kissingen, Schwalbach, 
and other German baths, undoubtedly have a very beneficial effect in 
reducing pelvic engorgement and allaying local and general neuroses. 

No other general means compare in result with a change of abode 
and corresponding change of air, habits, and associations. A removal, 
for example, to the seaside, where bathing can be enjoyed, a sea-voy- 
age, or a residence at an agreeable watering-place, may accomplish much 
good. Mental depression predisposes to and aggravates this disease 
most markedly. However this be, cheerful and congenial company 
certainly proves one of the best nervous tonics in a therapeutic point 
of view, and should always be sought for. A stay in a well-regulated 
hydropathic establishment, where the patient can have pure air, plain 
and nutritious food, and agreeable society, together with the strict atten- 
tion to the general rules of hygiene which characterizes those institu- 
tions, will produce the best effects. 

Depletion. — If vaginal touch and conjoined manipulation discover 
the fact that the uterus is tender, the occasional abstraction of small 
amounts of blood by puncture or scarification will be beneficial. Not 



DEPLETION. 327 

more than an ounce or two should be taken at once, unless amenorrhoea 
be a symptom. In case this be so, a more copious abstraction by leeches 
during the menstrual epoch will often give great relief. At times leeches 
then applied to the cervix will give great pain by their bites. This is 
sometimes so severe as to lead to the apprehension that one has escaped 
into the cavity ; hence it is important that they should be counted before 
being placed in the speculum and on their removal from it. 

The two methods by which local depletion of the cervix can be best 
practised are leeching and scarification. Three or four large leeches, 
or a sufficient number of small ones to take from three to five ounces 
of blood, may be applied in the following manner : A cylindrical specu- 
lum, of sufficient size to contain the entire vaginal portion of the cer- 
vix, being passed and the part thoroughly cleansed, a small pledget of 
cotton, to which a thread has been attached for removal, should be 
placed within the os, so as to prevent the entrance of the leeches to 
the cavity above. A few slight punctures, sufficient to cause a flow of 
blood, should then be made in the cervix, and all the leeches to be 
employed thrown in, and the speculum filled at its extremity by a dos- 
sil of cotton pushed toward the bleeding surface. The speculum should 
be watched until they cease sucking, for if left for a very short time, 
even with the mouth of the instrument filled with cotton, they will 
escape. After their removal all clots of blood should be removed by 
a sponge or a rod wrapped with cotton, the speculum withdrawn, a 
large sponge squeezed out of warm water placed over the vulva, and 
the patient directed to remain perfectly quiet. Should scarification be 
employed, a very sharp and narrow bistoury or tenotomy-knife may be 
introduced within the os, and drawn outward toward the vaginal edges 
of the cervix, so as to sever all the superficial vessels over which it 
passes. We would recommend, in preference to this plan, acupunc- 
ture, which may be performed by an ordinary three-sided surgical 
needle held in the grasp of a pair of forceps, or, still better, by a lit- 
tle spear-shaped scarificator with three edges. This little instrument, 



Fig. 148. 



E3 =C> 



».U*MAHf 



Spear-pointed Scarificator. 

when plunged about one-sixteenth of an inch into the cervix and given 
a rapid half turn before removal, causes a very free flow of blood should 
congestion exist. Cupping the cervix is no longer employed, being- 
found unnecessary. 

Dr. John Byrne of Brooklyn has drawn especial attention to still 
another method, which in some cases answers an excellent purpose. It 
consists in passing a long, delicate blade up the os internum, and cut- 
ting through the mucous membrane, its blood-vessels, and the super- 
ficial layer of muscular tissue as it is withdrawn through the os 
externum. Local depletion by one of these methods should be practised 
cautiously, the patient for twenty-four hours after its adoption being 
kept perfectly quiet in bed. 



328 AREOLAR HYPERPLASIA, OR CHRONIC METRITIS. 

It is surprising to observe how steadily depletion by all these means 
has been during the last ten years going out of vogue in New York. 
Many gynecologists with large practices have entirely given it up, and 
in the Woman's Hospital it has almost completely passed out of use. 
It must be remembered, however, that the same statement would hold 
good in reference to abstraction of blood in every other department of 
medicine. 

Still, we have seen great benefit follow the repeated scarification 
of the cervix in hyperplasia, especially to stimulate a scanty menstrual 
flow, and in chronic venous engorgement of the uterus, and leeching, 
while no longer as fashionable as it was, has done as excellent service 
in similar conditions. Let us warn, however, against allowing leech- 
bites to go unwatched during the first twelve to twenty-four hours, since 
very severe secondary hemorrhage may occur from them. It is better 
to insert a few tampons, covered with alum powder or soaked in pure 
vinegar, before leaving the patient, and to return within a few hours 
prepared to renew them if saturated with blood. 

Vaginal Injections. — A great deal of advantage accrues in these 
cases from the systematic use of very copious vaginal injections of 
water as hot as the patient can bear them. They should be employed 
for from fifteen to twenty minutes at a time and once in every twelve 
hours. Their use quiets pain, improves the pelvic circulation, removes 
irritating secretions, and unquestionably stimulates the absorption of 
effused material. 

Local Alteratives. — The best local alterative is the compound tinc- 
ture of iodine, which by means of a brush of pig's bristles should be 
carried up to the os internum, or even to the fundus should endometritis 
exist, and over the whole cervix ; then, waiting for complete drying, 
this process should be repeated. After these applications a wad of cot- 
ton, to Avhich a string has been attached in such a way as to leave its 
surface flat, should be saturated with glycerin and laid against the cer- 
vix. This acts as a local hydragogue and disgorges the tissues. These 
local applications should be repeated two or three times a week, but 
others may be made daily by the patient herself by means of vaginal 
injections, by which the drugs just mentioned may be brought in con^ 
tact with the cervix. 

Should it appear to the practitioner that persistent hyperemia 
requires more energetic means than those mentioned, resort may be had 
to counter-irritants which vesicate and destroy the mucous membrane of 
the vaginal cervix, and thus cause a free flow of serum. Such cases 
grow smaller and smaller in our practice as we grow older in expe- 
rience, and although we admit the occasional necessity of these means, 
we caution the reader against a constant or too early resort to their 
use. They cannot diminish the absolute size of the enlarged organ, 
and should not be used with any such view. They can remove con- 
gestion and nervous exaltation, and in certain exceptional cases may be 
employed for these purposes. 

Dr. August Martin of Berlin advocates amputation of one lip of the 
cervix for the induction of a species of involution in cases of areolar 
hyperplasia. Some time ago he reported 72 such operations, in only 7 



GRANULAR AND CYSTIC DEGENERATION 829 

of which did any inflammatory symptoms show themselves, and which 
were invariably followed by a diminution in the capacity of the uterus 
of from two to three centimetres. In a discussion which followed a 
paper by Martin, Kehrer, Schroeder, and Olshausen agreed with it. 
This method possesses none of the advantages of trachelorrhaphy, to 
which it is inferior in every respect, since it mutilates the cervix by 
entirely removing a portion of it, whereas trachelorrhaphy restores the 
part to its normal shape and condition. Both operations are usually 
employed where laceration of the cervix exists as a cause of the hyper- 
plasia. 

A wedge-shaped piece excised by knife or scissors from each lip, the 
acute angle of the wedge reaching to the vaginal vault, and the closure 
of the wound by wire sutures, as in trachelorrhaphy (we believe this 
operation was first advised by Simon of Heidelberg for this purpose), 
exerts a very beneficial influence in cervical hyperplasia by stimulating 
involution of the whole organ as well as of the cervix alone. 



CHAPTER XXIII. 
GKANULAR AND CYSTIC DEGENERATION OF THE CERVIX UTERI. 

No subject in connection with gynecology has attracted more atten- 
tion within the past fifty years than the so-called inflammatory " ulce- 
ration of the cervix uteri." Until a comparatively late period it was 
fully believed in, but as more careful observation has been practised 
the fact has been recognized that unless affected by direct pressure or fric- 
tion from some solid body the cervix uteri is little prone to simple ulcera- 
tion. It is, of course, everywhere admitted that cancerous and syphi- 
litic ulcerations may affect this part, but no one would propose to style 
these inflammatory ulcers. It is likewise admitted that in a prolapsed 
uterus friction against a pessary or the clothing commonly produces true 
inflammatory ulceration. But these admissions do not touch the point 
at issue, and it is fully agreed to-day that the condition styled inflam- 
matory ulceration by Dr. Henry Bennet and his school was not one 
of ulceration at all, but one of exuberant growth of the tissues of the 
cervix, with or without laceration of this part ; which is much more 
correctly described under the names which head this chapter. 

It not unfrequently happens that one symptom of a disease will so 
distress and harass a patient that remedial measures must be entirely 
directed to it, although the practitioner be aware of the fact that it 
depends on diseases elsewhere located. An example of this is fre- 
quently presented in the morbid state under consideration, which in 
itself proves so annoying by its profuse discharge and interference with 
the functions of the uterus and with locomotion as to call for prompt 
relief. 

The vaginal surface of the cervix uteri is covered by a smooth 
mucous membrane which is continuous below with that of the vagina. 



330 GRANULAR AND CYSTIC 

and extending through the cervical canal joins that of the body, which 
differs widely from it, at the os internum. This membrane is cov- 
ered by numerous papillae which become visible when a sufficiently 
strong glass is used. One or more slender blood-vessels pass into each, 
and form at their extremities vascular loops, then return, and at their 
bases pass into adjoining ones. They are completely covered by pave- 
ment epithelium and basement membrane. Throughout the cervical 
canal mucous crypts or follicles exist, which are likewise found scattered 
over the vaginal portion of the cervix. The diseases of two of these 
elements of cervical mucous membrane are now to engage our attention. 

Granular Degeneration of the Cervix. 1 

Definition. — This condition, which has been described under the 
names of erosion of the cervix, granular ulcer, and epithelial abrasion, 
consists, as its name implies, in the development of a surface of granu- 
lar character on the smooth face of the cervix and just within the os. 
Frequency. — It is an affection of great frequency, attending all the 
diseases of the uterus which result in leucorrhoea, and being commonly 
a concomitant of most of the diseased conditions of the parenchyma 
and lining membrane. It is, in fact, the most common consequence of 
chronic endometritis. Very often it exists for a length of time without 
any suspicion of its presence arising in the mind of patient or physician, 
and sometimes without causing symptoms which prove in any great 
degree annoying. "Whatever grave constitutional symptoms exist with 
this condition are not directly caused by it, but rather by the primary 
disease of which it is only a result. 

Causes. — The predisposing causes are — 

Enfeebled general health ; 

Spansemia ; 

The scrofulous diathesis. 
Those which are exciting are the existence of — 

Endometritis ; 

Laceration of cervix ; 

Displacements ; 

Areolar hyperplasia ; 

Abuse of sexual intercourse ; 

Pessaries which touch the vaginal face of the cervix. 
The last two are mereh~ accidental causes. 

From this array of causes it will appear that it is rarely a disease 
which stands alone, but that it is usually engrafted upon some other 
affection of greater moment. Although this is true, it will not do in 

1 [I have thought best to retain this section, although the condition here described 
is properly a symptom of chronic endometritis, and belongs in the chapter devoted to 
that disease. It was evidently the intention of the author to call special attention to 
this particular result of endometritis and to consider it a disease by itself, worthy of 
separate discussion. Appreciating the frequency and importance of this symptom, and 
the necessity for its recognition by the practitioner, I have decided not to change the 
author's plan. It should be distinctly understood that by the term " granular degen- 
eration " of the cervix uteri is meant merely a raw, rough, irregular, freely-discharg- 
ing or bleeding surface, all of which is due to abrasion of the epithelium and slight 
hypertrophy of the papillae. — P. F. M.] 



DEGENERATION OF THE CERVIX UTERI. 331 

practice to carry this view too far. At the same time that it must he 
admitted that granular degeneration, even of aggravated character and 
considerable proportions, affecting the vaginal face of the cervix and 
the distal extremity of the cervical canal, is commonly a consequence 
of some pre-existing disease, the fact must not be lost sight of that this 
affection of itself keeps up a hyperemia in the subjacent and neigh- 
boring parts of the uterus, and even extends a reflex influence to the 
ovaries. 

In general terms we may say that it is usually produced by — first, 
any disorder which keeps the mucous membrane of the cervix constantly 
bathed with ichorous fluids for a length of time ; second, by anything 
which keeps up friction against the cervix ; third, by any influence pro- 
ducing and perpetuating congestion of the uterus. Let the reader turn 
to the list of predisposing causes, and he will see that they are just such 
as to favor these morbid influences, and that the exciting ones are those 
which absolutely produce them. For example, displacements keep up 
congestion of parenchyma and mucous membrane, and produce uterine 
leucorrhoea and cause friction between the cervix, thus engorged and 
excoriated, and the vaginal surface. Hyperplasia produces displacement 
with all its results, furnishing in advance a tissue peculiarly prone to 
hyperemia and already abnormal in character. Laceration of the cer- 
vix is a fruitful source of cervical hyperplasia, and the eversion of 
mucous membrane which attends it establishes friction which results in 
leucorrhoea and increase of hyperemia. But it is unnecessary to apply 
remarks which are so obvious to each of the causes mentioned. 

Before Emmet pointed out the pathological bearing of laceration of 
the cervix a great many cases of that accident were regarded as granular 
degeneration. A careful differentiation must be practised with reference 
to the two affections, while at the same time a proper degree of weight 
should be given to the fact that granular degeneration often occurs in 
virgins and involves the whole vaginal face of the cervix. 

Symptoms. — Should granular degeneration exist with but trivial 
disorders of the uterus of any other kind very few symptoms may be 
present. Indeed, profuse leucorrhoea is sometimes the only one of which 
the patient will complain. The fact that other and more serious symp- 
toms generally show themselves is a corroboration of the statement that 
graver disease of the uterus constitutes an important element in such 
cases. Ordinarily, these are the symptoms which will be noticed in a 
case of the more serious kind : 

Profuse bloody and purulent leucorrhoea ; 

Pain and hemorrhage after intercourse ; 

Menorrhagia or metrorrhagia ; 

Pain on locomotion ; 

Bearing-down sensations ; 

Fixed pain in back and loins ; 

Tendency to spanaemia ; 

Nervous disorders and perhaps hysteria. 
Physical Signs. — Vaginal touch alone might serve as a diagnostic 
means, for by it the cervix is felt to be covered by a velvety or granular 
surface, which, to the practised finger, is at once recognizable. But the 



332 GRANULAR AND CYSTIC 

speculum offers the fullest corroboration or corrects any error committed 
by this means. By it the cervix, more especially near the os, is seen 
to be covered by a mass of muco-pus, which being removed lays bare 
an intensely red, granular, hemorrhagic-looking space of greater or less 
extent, closely resembling the inner surface of the eyelids when affected 
by granular degeneration. The diseased surface does not appear de- 
pressed below, but is sometimes even elevated above the surrounding 
mucous membrane. 

Course and Duration. — The disease is unlimited. If the general 
health improve, it is possible that nature may effect a cure without the 
aid of local treatment, but such a result should not be anticipated. The 
degenerated surface may go on for an unlimited time pouring out pus, 
and thus in predisposed subjects greatly impoverish the blood and cause 
grave constitutional results. 

Pathology. — According to Ruge and Veit, the maceration of the 
cervical mucous membrane in ichorous fluids results in the desquama- 
tion of epithelium to such an extent that only one layer of cells exists, 
through the diaphanous structure of which the red-colored tissue beneath 
is visible with its exaggerated vascular supply. 

Very soon from the epithelial layer prolongations project inward, 
dividing the subjacent tissue into villi or processes, such as are formed in 
the vesical and uterine mucous membrane. These villous projections 
are new formations, not hypertrophied papillae. They are covered with 
epithelium, richly supplied with superficial blood-vessels, and liable to 
increase to large masses. To these in former times the now obsolete 
names of " bleeding ulcer " and " cock's-comb granulation " have been 
given. 

Prognosis. — The prognosis in this affection is always good, though 
it may require a great deal of time to effect a cure, for this will not be 
permanent unless that of the coexisting disease be accomplished. 

Treatment. — Before treatment for this condition is commenced let 
us urge the practitioner to examine carefully as to whether he is really 
dealing with a case of granular degeneration or with one of cervical 
laceration. The two conditions closely resemble each other ; the former 
often complicates the latter, and a treatment which is appropriate to the 
one is utterly insufficient for the other. 

Granular degeneration being generally a secondary disorder engrafted 
upon a pre-existing one, before treatment is adopted the primary disease 
should be sought for, and both should be treated simultaneously. 

Having presented these remarks and sufficiently insisted upon their 
importance, w T e now proceed to the consideration of the special treat- 
ment of the condition itself. Before commencing treatment the general 
health should receive especial attention, those tonics and hygienic direc- 
tions which appear best suited to the particular case being given. These 
indications should from the commencement be as far as possible ful- 
filled : first, the granular surface should be put beyond the influence of 
friction ; second, it should be protected from contact with ichorous dis- 
charges ; third, a steady alterative influence should be exerted upon it 
by local applications ; and fourth, congestion of the uterus and of the 
especial part diseased should be prevented. 



DEGENERATION OF THE CERVIX UTERI. 333 

To accomplish the first indication the uterus, if displaced, should be 
put and kept in position by a well-fitting pessary. Even if its axis be 
normal, it is often excellent practice to lift it out of the pelvis by an 
elastic ring. At the same time such support prevents a tendency to 
congestion of the organ, and may be rendered more effectual by careful 
removal of all weight from the abdomen by tightly-fitting or heavy 
clothing. Let no one who has not tried this as an adjuvant undervalue 
it, for there can be no question of its great utility. 

In fact, practically the same treatment should be employed as has 
been recommended for chronic endometritis. Among those remedies 
which the patient can employ herself stands foremost the persevering 
use of copious hot vaginal injections, or "douches," as they are now 
generally called, taken in the dorsal recumbent posture, from an irri- 
gator or fountain syringe, twice daily, at a temperature of 115° to 
120° F., for ten or fifteen minutes. 

The best topical application to the diseased surface is the sharp steel 
curette, followed by the immediate use of strong nitric or chromic acid, 
and, when the slough has separated, by dry tannin or iodoform powder, 
either separate or, as we prefer, mixed in equal parts, and retained in 
position by a dry cotton or wool tampon. These last applications must 
be repeated every other day until the wound is healed. Exuberant 
granulations can be removed with the sharp curette or scissors, and 
then treated as above. 

Should simple eversion of the cervix exist, the hemorrhoidal mucous 
membrane should be at once removed by the scissors or destroyed by 
fuming nitric acid. When this is excessive and due to laceration of 
the canal by parturition, the condition may be cured by an operation 
which consists in paring with long scissors the edges of the cervical fis- 
sure and passing deep sutures of silver wire so as to approximate them 
thoroughly. By this means the os is restored to its integrity, and the 
everted mucous surfaces being placed face to face, friction against them 
is prevented. 

The last indication in enumeration, but not in importance, is the 
prevention of congestion, local and general. To a certain extent this 
is accomplished, locally, by all the alterative and astringent applications 
alluded to, and the same thing may be furthered by vaginal supposi- 
tories and injections. Should any case prove very obstinate, this end 
may be more decidedly attained by taking a sharp-pointed, curved bis- 
toury and beginning as high up the cervix as the disease extends, cut- 
ting through the mucous membrane and submucous tissue, extending 
the incision outside the os as far as the surface is affected. Five or six 
such superficial and painless incisions sever the network of little vessels 
in the submucous tissue, and, for the time at least, interfere with the 
circulation. 

Congestion of the whole uterus is greatly relieved by removal of 
weight from it by abdominal and skirt supporters ; avoidance of muscu- 
lar efforts ; the use of a pessary ; careful regulation of the bowels : rest, 
especially during menstruation ; and the use of copious hot vaginal 
injections. 

Applications should be made not only by the physician, who will 



334 GRANULAR AND CYSTIC 

probably use the speculum not oftener than once a week, but also by 
the patient, who should make them daily by injections and suppositories. 
The former should be thus employed : every night and morning a gal- 
lon of hot water, containing one ounce of glycerin and one drachm of 
sulphate of zinc, or two of sulphate of alum, acetate of lead, or tannin, 
should be injected for a period varying from ten to twenty minutes. Or 
if it be found necessary to employ a stronger astringent solution, a 
gallon of pure water may be used first for the time mentioned, and 
then a medicated solution, one quart in amount, be used for a short 
time afterward. 

Vaginal suppositories, containing one or the other of the above 
substances in greater proportion than could be administered in solution 
by injections, have fallen into disuse for diseases of the cervix. They 
are now used chiefly for obstinate leucorrhoea in virgins, where the 
hymen prohibits the usual treatment through the speculum. 

Cystic or Follicular Degeneration of the Cervix. 1 

Definition. — This form of disease, though not so frequent as that 
last mentioned, is by no means rare. It consists in an inflammation 
of mucous follicles, which resemble those of the cervical canal, and 
which are scattered over the vaginal face of the cervix and exist even 
in the cavity of the womb. " The cervical mucous cysts," says Farre, 



Fig. 150. 




Catarrhal Erosion of Cervix (after Papillary Erosion of Cervix (after 

L. Heitzmann). L. Heitzmann). 

" are lined by epithelium and basement-membrane. They contain a 
small quantity of mucus, together with granule-cells. Those upon or 
near the margin of the os uteri may be sometimes observed to contain 

1 [As " granular degeneration " of the cervix is a result of chronic endometritis, so 
may cystic and follicular degeneration follow the same disease. But, in addition, the 
latter conditions are very commonly found in cervices which have undergone par- 
turient laceration, and are among the usual results of that lesion. I have retained this 
section, instead of incorporating it in the chapter on Laceration of the Cervix, for the 
reason already given. — P. F. M.j 



DEGENERATION OF THE CERVIX UTERI. 



short papillae within their margin. 



A recollection of these facts 




is 

essential to a full understanding of the stages of this form of degene- 
ration. 

Pathology. — Follicular disease of the cervix shows three entirely 
different phases: 1st. A number of vesicles, equal in size to a millet- 
seed and filled with a fluid like honey, is noticed covering the part. 
These are due to repletion from retention of the secretion of the folli- 
cles. 2d. These cysts are seen open — i. e. they burst — and a depression 
marks the former site of each. 3d. The papillae contained in the mucous 
membrane undergo hypertrophy, F 

and cause the appearance of red, ele- 
vated, hemorrhagic-looking tuber- 
cles in place of the depressions just 
mentioned. Usually the cervix is 
soon studded over by little globular 
bodies about as large as a hemp- 
seed, with here and there a depres- 
sion, and here and there a promi- 
nence of red and irritable-looking 
character. 

Synonyms. — It will now be 
appreciated why a variety of names 
should have been applied to this 
disease when examined at different 
stages. Follicular disease is sup- 
posed to be the source of the erup- 
tive affections described by authors as acne, herpes, and aphthae of 
the uterus — terms which are now obsolete, and are replaced by that 
used by us, or, if the degeneration is excessive and simulates an actual 
neoplasm, by the words "cystic hyperplasia." 

Causes. — Anything which keeps up congestion in the cervical 
mucous membrane may give rise to this affection of the mucous glands 
of the vaginal cervix. Among the chief are — 
Cervical endometritis ; 
Cervical hyperplasia ; 
Laceration of the cervix. 

Prognosis. — If a few scattered cysts appear, the prognosis is 
decidedly favorable ; but in certain rare cases, where the whole of the 
extremity of the cervix is filled by them, nothing but excision of the 
diseased tissue, or even amputation of the part containing them, accom- 
plishes cure. 

Treatment. — The contents of all the cysts should be evacuated by a 
bistoury, and their cavities' thoroughly cauterized by a sharp point of 
nitrate of silver, chromic acid, or nitric acid. Should the second or 
third stage exist, the diseased surface should be treated upon very much 
the same plan as that advised for granular degeneration. 

Should a great amount of cystic degeneration exist, and cure not 
follow evacuation and cauterization of the cysts, the diseased portion o( 
the vaginal face of the cervix should be removed by bistoury or scis- 
sors, and, if feasible, the edges of the wound drawn together by catgut 



Cystic Erosion of Cervix (after L. Heitzmann). 



336 SYPHILITIC ULCER OF THE CERVIX UTERI 

or wire sutures. Here, as in cervical endometritis of cystic character, 
the rule of surgery which inculcates the ablation of a" part which is 
the habitat of a disease which proves incurable by minor means should 
be followed. 



CHAPTER XXIV. 

SYPHILITIC ULCER OF THE CERVIX UTERI. 

Frequency. — Syphilis may affect the cervix uteri either as a primary 
or secondary disorder, though in neither form is it by any means com- 
mon. It is now a settled fact that true chancre may locate itself upon 
the cervix, but not the less certain is it that it rarely does so. We 
have seen but one case which we felt satisfied was of this character. 
This was proved by inoculation, the most certain way in which a strictlv 
reliable conclusion can be arrived at, and by corroborative evidence 
existing in the presence of syphilitic roseola without primary disease 
elsewhere. M. Bernutz, who has made, according to Becquerel, 1 a 
special study of this subject in the hospitals of Paris, describes chancres 
of the os minutely, dividing them into Hunterian, diphtheritic, and 
ulcerous, which resemble phagedenic very closely. With regard to 
secondary affections on the cervix, there has been considerable discus- 
sion, some regarding them as quite common, others as very rare. Bec- 
querel, after careful research in L'Ourcine Hospital at Paris, was con- 
vinced of their occurrence, and Bernutz describes mucous patches, 
vegetations, erosions, tubercles, and gummy tumors. We know of no 
more significant evidence of the rarity of these affections upon the 
cervix than the fact that in a recent work upon syphilis — a work 
remarkable for the thorough and comprehensive style with which it 
deals with all relating to that subject — almost no mention is made of 
syphilitic affections of the cervix. We allude to the work of the late 
Professor Bumstead. 2 The author investigates the character of syphilis 
when affecting all parts of the body, even the lachrymal sacs, the mem- 
brana tympani, etc., but nowhere is any mention made of the disease 
appearing on the cervix, except a cursory statement that at Bellevue 
Hospital he had seen some remarkable instances of mucous patches 
thus located. The sign of the secondary disorder which we would most 
naturally expect to find in this site w~ould be the mucous patch, as it is 
one of the most frequent of all the manifestations of that stage ; but 
we are informed by MM. Davasse and Deville 3 that of one hundred 
and eighty-six women affected by syphilis and examined in reference 
to the location of its lesions, they were found on the cervix uteri but 
once. 

1 Mai. de /' Uterus, vol. i. p. 169. 2 Bumstead on Venereal Diseases. 

3 Davasse and Deville, "Des Plaques muqueuses," Arch. gen. de Med., 1845, t. ix. 
et x. 




SYPHILITIC ULCER OF THE CERVIX UTERI. 117 

The gynecologist, in our experience, has but few opportunities to see 
this disease, because his practice is more likely to be among the more 
respectable classes of females, who are 
not often exposed to venereal infection ; Fig. 152. 

and even the practitioner whose clientele 
is composed largely of prostitutes will not 
recognize syphilitic ulcer of the cervix 
frequently, since it can only be discov- 
ered by the speculum, and this may not 
be called for until long after the damage 
is done, the disease transmitted, and its 
nature revealed by secondary manifesta- 
tions. [I have seen but one case of true 
chancre of the cervix before the appear- 
ance of roseola or later secondary symp- 
toms. This patient, a " femme entre- 

tenue," was sent me by the gentleman Syp * vix (after L. a Heitzmaim). ul ** 
interested, because he suspected from 

certain appearances on his glans penis that something might be wrong. 
A specular examination showed a yellow, slightly depressed, circular 
ulceration of the external os. The diagnosis of true chancre was con- 
firmed two weeks later by a distinct roseola, and the patient's male 
friend eventually went through a severe experience with the constitu- 
tional symptoms. — P. F. M.] We would refer the reader to Bumstead k 
Taylor's work, or to other modern works on venereal disease, for a full 
description of this form of that disease. 

Course and Termination. — The primary affection being located on 
the cervix, the general system becomes affected as from a chancre on 
any other part, and, as M. Gosselin has pointed out, instead of passing 
off rapidly, as it sometimes does, it may assume the fungous type. 
During its course the cervical chancre has a marked tendency to 
become covered by false membrane, which Robert 1 first noted and 
Bernutz subsequently corroborated. Unless a fact corroborated by 
Forster 2 be carefully borne in mind by the diagnostician, a grievous 
error may occur in the differentiation of this form of ulcer from malig- 
nant disease. He declares that syphilitic ulcers sometimes destroy tis- 
sue so freely as to penetrate into the bladder or rectum. 

Differentiation. — For evident reasons, this is a matter of great 
importance, not only as regards therapeutics, but because it may 
involve a delicate legal question affecting the chastity of the woman. 
These are the means of diagnosis in cases of chancre : 

Border of ulcer precipitous ; 

Surface of ulcer depressed ; 

Yellow, opaque color ; 

Rapid development of constitutional symptoms : 

Early appearance of roseola ; 

Transmission by inoculation. 
All of these signs are of value, but the only ones upon which a posi- 
tive opinion could be based are the last three. 

1 Aran, Mai de VUt&ms, p. 5'24. 2 Klob, op. cit., \k 243, 

22 



338 UTERINE FUNGOSITIES. 

Secondary eruptions— as, for example, mucous patches, vegetations, 
etc. — which appear here will be known by — 

Their rapid development ; 

Their connection with constitutional signs ; 

Simultaneous affection of the vagina ; 

Absence of chronic cervical inflammation ; 

The peculiar appearance of secondary eruptions. 
Treatment. — This will consist in cases of chancre of the ordinary 
treatment adopted when such an ulcer affects any other part. In cases 
of secondary affections the patient should be put upon a mercurial 
course, the surface cauterized, and subsequent dressings made of mer- 
curial preparations, of which the black or yellow wash, mercurial oint- 
ment, and calomel are the best. 



CHAPTE R XXY. . 
UTEBINE FUNGOSITIES. 

History. — The fact that the lining membrane of the uterus becomes 
covered to a greater or less degree with fungous masses which have 
a marked tendency to bleed was announced by Re'camier, who not only 
described them, but gave us the best method yet devised for their relief. 
After attention was called to the subject by him, theses were written 
upon it in Paris and Strassburg by Rouyer and Goldschmidt, and the 
subject attracted a great deal of notice in France, and received the 
attention of such men as Marjolin, Robert, Trousseau, Nelaton, Maison- 
neuve, and Nonat, who not only adopted Recamier's pathological views, 
but endorsed and practised his method of treatment. After many years 
of trial this contribution of the great French gynecologist may be 
regarded as by no means the least valuable of the many which he has 
made to this department. For a long time kept sub judice, it has of 
late years found its way into the textbooks. 

Definition. — Uterine fungosities may be defined as fungous projec- 
tions from the endometrium, the result of prolonged congestion from 
any cause or of the organization of portions of placenta remaining 
attached to the surface. Under this head, of course, carcinoma and 
sarcoma of the endometrium might, through an error in diagnosis, be 
brought, but the nature of those grave disorders being once recognized, 
no one would think of classifying them under it. Upon theoretical 
grounds objection might be raised to classifying under the same head 
hyperplasia of the lining membrane of the uterus and remains of the 
placenta, but as the symptoms and treatment of the two conditions are 
identical, and there is no means of differentiating one from the other, 
it seems better for practical purposes to consider them together. 

Frequency. — Fungoid degeneration of the endometrium is an affec- 
tion of great frequency — one which plays the part of an important 



CA f T SES. 



339 



Fig. 153. 



factor in metrorrhagia and monorrhagia, and which often saps the 
health of patients in whom its existence remains for years unsuspected. 
The practitioner who recognizes the important bearing of this subject 
will find himself prepared to cope with many cases of chronic endome- 
tritis, monorrhagia, metrorrhagia, and uterine enlargement which before 
proved entirely rebellious to treatment. 

Synonyms. — The disorder is sometimes described as hemorrhagic, 
granular, hyperplastic, or polypoid endometritis, or, as Slayjanky styles 
it, "internal villous metritis." 

Pathology. — Uterine fungosities will usually be found to exist as a 
consequence of uterine engorgement, however kept up, or of abortion or 
labor. We have also repeatedly seen them in young women at the age 
when menstruation is establishing itself, and found them 
under those circumstances produce a most excessive and 
dangerous degree of hemorrhage. In the first condi- 
tion mentioned prolonged congestion creates a hyper- 
genesis of tissue which results in hyperplastic growths 
upon the endometrium. In the second, if a large por- 
tion of placenta remained attached in utero, what is 
sometimes styled a placental polypus would be created, 
but small portions only being here and there attached, 
these little fungosities are the result. In the third con- 
dition the great impetus given by puberty to sexual 
growth in the developing girl seems to affect the uterine 
lining so as produce localized hypertrophies upon its 
surface. 

Under the microscope these growths, if the result 
of hyperplasia and not of retention of small portions 
of placenta, are found to consist, according to Dr. F. 
Delafield, who has repeatedly examined them for us, of 
hypertrophied elements of the mucous membrane, dilated follicles, 
enlarged blood-vessels, and exaggerated cell-growth. Sometimes the 
amount of material removed at one time will amount to one, two, or 
three drachms, and its appearance will make one instinctively dread 
the existence of a malignant basis ; but the microscope will commonlv, 
even in such cases, convey the comforting assurance to the contrary. 

It should again be mentioned, however, that the true intra-uterine 
fungosities in no way depend upon, or are connected with, the pre- 
existence of conception or the retention of placental villosities. The 
fungosities occur entirely independently as the result of chronic ute- 
rine congestion and hyperplasia, and have been grouped by Gorman 
authors under the generic heading of adenoma, or glandular neoplasms. 
Causes. — The causes may be enumerated as follows : 

Abortion, or labor at full term ; 

Endometritis ; 

Subinvolution ; 

Laceration of the cervix : 

Uterine displacement of any variety : 

Fibromata, submucous or interstitial. 
All these, except the first, seem to produce the condition by exaggerat- 




Multiple Adeno- 
ma, or so-called 
Uterine Fungos- 
ities (Winckel). 



340 UTERINE FUNGOSITIES. 

ing formative development or by keeping up engorgement of the uterine 
lining membrane. 

Symptoms. — There is but one symptom which has any significance; 
that is uterine hemorrhage. This may consist only in a great exagge- 
ration of the menstrual flow or in profuse metrorrhagia. Whenever 
either or both of these is present without other assignable cause, these 
growths should be suspected. For example, a patient has lost a great 
deal of blood from the uterus, and an abnormal condition is strongly 
suspected as the cause of the excessive flow ; no laceration of the cer- 
vix is found to exist, or at least none which could account for the hem- 
orrhage, no neoplasm of any kind is discovered, and no large portion 
of placenta is supposed to be in utero ; under these circumstances fun- 
gosities should always be suspected and their existence determined 
by physical examination. The method of deciding the question is so 
simple that it should, under these circumstances, be unhesitatingly 
employed. 

Physical Sigiis. — Fungosities being suspected to exist, the patient 
should be examined with Sims's speculum. After its introduction the 
cervix should be held by the tenaculum, and, if the os externum or cer- 
vical canal be very small, it should be gently stretched with a steel two- 
or three-branched dilator (Ellinger's or one of its modifications or 
Sims's) until it will admit the little wire curette to be shown farther on 
in this chapter. An ordinary looped wire answers very well, and we 
have even made a loop of a lady's hairpin, bound it with waxed thread 
in the bite of the forceps, and employed that. 

All being now prepared, the loop of the wire curette is passed in 
and drawn gently down the anterior face of the uterine cavity, then 
of the posterior, and then of each horn. As it is withdrawn after 
making each exploration, it is examined to see if it has dislodged a 
fungosity. If there be any within the cavity and the instrument be 
not held in very unskilful hands, one or more will be looped off. 
These may, for greater certainty of diagnosis, be put under the micro- 
scope. In some cases a mammilloid process of mucous membrane will 
be found covered with epithelium placed edgewise upon it with great 
regularity ; in others a piece of placenta will be seen ; while in a few 
cases the tale will be told of commencing cancer or sarcoma, which will 
yield to no treatment whatever, except the extirpation of the whole 
uterus. 

It has been said that the curette gently passed over the endometrial 
surface will reveal little irregularities, even if it do not remove them ; 
and in very marked cases this is true, but he who relies upon this as a 
crucial test will pass over many minor cases requiring diagnosis and 
treatment scarcely less than they. The wire loop should be regarded 
as a valuable diagnostic resource in all endometrial outgrowths. 
Employed as such as freely as we make use of it, we have yet to see an 
accident follow its introduction if applied with caution. 1 We have seen 

1 I have recently seen a perforation of an unusually soft fundus uteri take place 
with the flat sharp curette in my own hands in a case where I was curetting the uterine 
cavity for hemorrhage following a probable early absorption. Is o force had been used, 
but the curette suddenly slipped through the right horn of the fundus. The cavity 



COURSE, DURATION, AND TERMINATION. 341 

the uterine sound excite peritonitis, but never the wire loop used gently 
for the purpose merely of diagnosis. By its instrumentality the pow- 
erful aid of the microscope is put at our service, and many an obscure 
case will be made clear, many a doubtful one set at rest by the combi- 
nation. 

Course, Duration, and Termination. — These growths may last, 
producing their evil results, for years — not increasing at all, but not 
diminishing. If the patient become pregnant, the changes of parturi- 
tion seem in some cases to destroy their activity, but even this they at 
times resist, and after delivery the case goes on as before. 

Sometimes the little growths will be cast off and appear in the 
menstrual discharge. But this casting out does not go on to cure. If 
not interfered with, they will commonly annoy and weaken the patient 
until the menopause, when, notwithstanding their presence, the uterine 
flow will usually cease. We say "usually," for the reason that in some 
cases it will obstiuately continue at irregular intervals for years after 
its occurrence. 

The remedy to which we have made allusion as having been intro- 
duced by Recamier is the use of the curette, which meets the require- 
ments of the condition perfectly. It must not, however, be supposed 
that one or even several applications of the curette will uniformly cure 
these cases ; many of them will prove very obstinate, rebellious, and 
perplexing. [Some years ago I attended, with Dr. Fessenden of 
Brooklyn, a young lady of sixteen who, ever since the establishment of 
menstruation, had lost blood so freely at her periods as to be alarmingly 
exsanguinated. I employed the wire curette and removed a great num- 
ber of large growths, and she got up apparently well. In three months, 
however, her dangerous symptoms returned, and the operation was 
repeated, and followed by injection of compound tincture of iodine into 
the uterine cavity. Again she got better, and again had a relapse 
after a few months. Sims's cutting currette was then employed, and 
after its use nitric acid was applied by Lombe Athill's method. After 
this Dr. Fessenden occasionally made an application of iodine to the 
uterine Cavity, and she ultimately recovered. 

In another case which I attended with Dr. L. M. Yale of New York 
the curette was, during the course of three years, used ten times, very 
large quantities of fungous growths being each time removed, and the 
application of the instrument, Sims's being sometimes employed, and 
at other times mine, followed by free applications of iodine or nitric 
acid. After a time we felt sure that sarcoma or cancer must be the 
basis of the affection, but Dr. Delafield cheered us with the assurance 
that this was not so, and the justice of his statements was verified by 
the entire recovery of our patient. In a great many cases I have had 
to repeat the operation of scraping about once a year for a long time. 
so that now I always guard my patients against this possibility for fear 
of their being disappointed at the result. — T. G. T.I 

of the uterus was at once swabbed with tincture of iodine to exeite its contraction, 
loosely packed with iodoform gauze, an ice-bag applied, and the patient put to bed. 
She made a smooth recovery. — P. F. M. 



342 UTERINE FUNGOSFFIES. 

I also have met with several similar eases, bur only in one in.-tanee — 

that of a lady sent me by Dr. Joseph Anderson of this city about two 

years ago — did I fail to effect a permanent cure. But I have always been 

careful to continue the intra-uterine applications of tincture of iodine twice a 

week for several months, until the menstrual flow became normal in amount. 

In the case of failure just referred to. the patient had been curetted 

several times, and treated by intra-uterine applications for six months I : 

I saw her by a well-known lady physician of recognized ability. I repeated 

the curetting and applications, but the metrorrhagia continued. Finally. I 

up her lacerated cervix and kept her retroflexed uterus straight with a 

glass stem and lever pe-sary inserted immediately after the operation by 

advic-c of Dr. Thomas, to whom I sent the lady for an opinion . but all in 

vain. Her physician tells me that she still menstruates profusely, and she 

herself confirmed his statement on a visit to my office nearly two years after 

sed treating her. I cannot but think that a constitutional tendency to 

hemophilia exists in this case. Reeves Jackson of Chicago has recently 

rted several similar ca^es from his own practice. — P. F. Bf.] 

Another curious fact connected with this operation, which we are 
at a loss to account for. is the irregularity in menstruation which 
sionallv follows it. The period next succeeding the opei ition will pos- 
siblv be as profuse as those before it. but after this the patient may 
menstruate very irregularly. 
Results. — Directly: 

Menorrhagia : 

Metrorrhagia : 

Leucorrhcea. 
Indirectly : 

S] anaemia : 

Sterility : 

( . :;-titutional feebleness. 
Progn^si*. — This will depend in great degree upon the treat- ot 
adopted. If the practitioner be one of those who abhor a resort to 
even the simplest surgical procedures, and who rely upon ■: institutional 
treatment in all these affections, the pros] sets : the | atient for : 
erv are poor. If. on the other hand, the procedure about tc lescribed 
heVe be resorte I to. recovery is as certain as the method is simple and 
safe. 

Treatment. — Piecamier advised the introduction into the uterus oi 
small scoop called the curette, by which these growths could be gently 
scraped off. His advice, although followed by some able men. was n t 
generally accented, and his method excited a great leal : hostility, 
which even now has not wholly passed away. The reason for this was. 
we think, the fact that the instrument employed for the procedure wj - - 
rough and harsh. At a later peri 1 Sims introduced the steel curette 
shown in Fi^r. 155. This was an advance over Recamier's nietl 
the superioritv of the means for attaining the end. But even the use 
of Sims*s cutting steel instrument was t langerous, and the operation 
remained imperfect. For a number of years we have employ t j tt 
instrument shown in Fig. 156. I: consists : sopper wire with a 
small loop at its extremity. The loop is slightly flattened at its edges. 



TEE A TMENT. 



but still it is not a cutting instrument. Even if applied with force it 
can do no serious damage. It removes the growths by looping them 



Fig. 154. 



Fig. 155. 



Fig. 156. 



Recamier's Curette. 



Sims's Steel Curette. Thomas's Dull Wire Curette. 



off, not by cutting or tearing the endometrium. We employ it very 
largely in practice, and never yet have we had any accident follow its 




J>.H. SCHMIDT. 

Munde's Flat Sharp Curette (two sizes 



use in hundreds of cases. Of course, as there are instances in which 
the passage of a uterine sound will cause peritonitis, so there are those 
in which this operation may end fatally, but we have never met with 
one, and no one could use it more freely than we do. 

[In a very few rare cases in which the wire curette fails to effect a cure 
I employ Sims's more, powerful instrument, but never do I do this without 
good reason.— T. G. T.] 

[Whenever the dull curette of Thomas proved insufficient, I have for 
years made use of the flat sharp curette shown in Fig. 157. which was 
made for me in two sizes, on the principle of Thomas's instrument. It 
seems to me the least dangerous of all the sharp curettes, while answering 
every purpose. — P. F. M.] 



It is well always to tampon the vagina thoroughly with iodoform 



344 UTERINE FUNGOSITIES. 

gauze after curetting, and often slip a thin strip of the same material 
into the uterine canal to facilitate drainage. The failure to tampon the 
vagina carefully may result in a sudden call during the ensuing night 
on account of a more or less severe hemorrhage, and the unpleasant 
necessity of tamponing then. As a guard against hemorrhage, and 
also to procure a more thorough result, Ave usually plug the uterine 
cavity with a cone of absorbent cotton saturated in compound tincture 
of iodine, which, with the vaginal tampons, is removed in forty-eight 
hours at the latest. Whether the tampons are then to be replaced by 
fresh ones depends on the case. 

After the operation the patient should be kept perfectly quiet in 
bed for three or four days, and any tendency to inflammation at once 
met by the treatment appropriate to peritonitis. 

Dangers of the Curette. — The dangers which attend upon the use 
of the curette are — 

Peritonitis ; 

Cellulitis ; 

Atresia of the uterine canal ; 

Hemorrhage some hours after operation. 
We have seen the first follow the use of the sharp steel curette, never 
of the wire. It should be guarded against by care after operation, per- 
fect rest for several da}^s, ice to the hypogastrium, and the free use 
of opium in case of pain. The second is likely to occur in cases in 
which cellulitis has existed in chronic form before resort to the curette. 
The third we have seen in one case after the whole corporeal and cer- 
vical lining was thoroughly scraped by the cutting curette. The fourth, 
which we have once met with, may readily be prevented by the use of 
a uterine and vaginal tampon, as described. 

Fig. 158. 



Emmet's Curette Forceps. 

Emmet, in the hope of avoiding these dangers, recommends in place 
of the curette the use of a pair of forceps with cutting edges shown in 
Fig. 158. By these the fungoid growths are seized and removed by 
alternate separation and approximation of their blades. 

We have seen a severe pelvic inflammation follow sharp curetting of 
the cervical cavity, even, in several instances, when all the usual pre- 
cautions against infection and inflammation had been carefully observed 
and the patients put to bed at once with an ice-bag over the hypogas- 
trium. We have learned, therefore, to be scrupulously careful even in 
apparently trivial operations, so as to avoid any possible evil result. 



LACERATION OF THE CERVIX UTERI 345 



CHAPTER XXVI. 
LACERATION OF THE CERVIX UTERI. 

Definition. — This lesion consists in the traumatic division of the 
lips of the intra-vaginal portion of the cervix to a greater or lesser 
depth, and involving all or a portion of the tissues of the part. Lacera- 
tions of the upper portion of the cervix, not involving the external os, 
are not included in the injury now under consideration, being classed 
under the head of rupture of the parturient uterus. 

History. — It has long been known that during the last part of the 
first stage of labor, as the presenting part of the child escapes from 
the uterus and enters the vagina, the circular fibres of the os externum 
and of the vaginal portion of the cervix not infrequently give way 
under the excessive distension which occurs, and lacerations in one, two, 
or more directions take place. In 1851, Sir James Simpson 1 drew 
attention very fully to this subject, pointing out the facts that lacera- 
tions of the cervix uteri are of very frequent occurrence, that they are 
not the result of mismanagement, that they are so common after first 
labors as to be regarded as reliable signs of labor having occurred, and 
that they may be complete or may involve only the mucous and middle 
coats of the cervix. 

Some of the evil results of the condition too were recognized, as will 
be seen by reference to Dr. Gardner's work upon sterility (published in 
1856), where it is credited with the causation of hypertrophy of the 
cervix, ulceration, cervical catarrh, sterility, and abortion. 

Prof. Roser of Marburg in 1861 wrote of " ectropium" of the cervix 
as a cause of so-called ulceration of that part, but failed like his prede- 
cessors to recognize its true significance. 

But the important pathological bearings of this accident upon disor- 
ders of the uterus has been appreciated only of late years. The credit 
of having recognized the significance of the lesion, and of having fur- 
nished us with a safe and efficient means of cure, belongs to Dr. T. A. 
Emmet. The future of his operation for its relief will unquestionably 
be a long and brilliant one, and its results will effect a great deal of 
good for uterine pathology. Dr. Emmet, after having performed the ope- 
ration for seven years, published his first paper upon it in 1869. It was 
not, however, until a second paper by him in 1874 that the importance 
of his discovery was fully appreciated. Since that period the operation 
has gradually risen in favor, although the significance of the injury 
has undoubtedly been exaggerated by many who have performed the 
operation for its cure without a proper appreciation of the indications. 
We are now gradually arriving at the correct level, and it is surely not 

1 Edinburgh 'Journ. of Med. Science, p. 488, and works of Sir J. Simpson, Am. ed., 
p. 452. 



346 LACERATION OF THE CERVIX UTERI. 

too much to say of it that this discovery constitutes one of the most 
important contributions to gynecology which has ever been made. 

Etiology. — The rapid forcing of the presenting part of the child 
through the, in such cases, as yet imperfectly dilated cervical canal 
and external os is the cause in the large proportion of instances of the 
laceration. Early rupture of the membranes before the cervix has 
become softened, dilated, and retracted over the presenting part, and, 
above all, unusually severe and protracted expulsive efforts of the ute- 
rus, by which the child is rapidly forced through the cervical canal and 
perhaps out of the vagina, bear the chief blame in the production of a 
lacerated cervix. More or less important parts in the causation of this 
injury are played by a rigid os, faulty development of the cervix, cystic 
disease of that part, cicatricial induration, and hyperplasia. The unskil- 
ful use of the obstetric forceps may also cause this accident, although 
but a small minority of the cases occur in this manner. 

It is natural for a woman, when informed that her cervix is lacerated, 
to blame her physician for not having prevented it or repaired the injury 
at once. Of course we always follow the rule of exonerating the medi- 
cal attendant from any blame in connection with the accident, but we 
cannot in our own minds do the same for him for not having attended 
to the subsequent treatment — that is to say, possibly operation of the 
laceration. Therefore we advise that every woman in whom examina- 
tion made immediately after confinement shows a laceration of cervix or 
perineum should be again examined several months later in order to 
ascertain whether the injuries referred to require treatment or operation. 

We do not think that we exaggerate when we say that all fissures of 
the cervix which give rise to symptoms or produce pathological changes 
in the pelvis are the results of parturition. The division of the cervix 
by scissors or the knife for the cure of sterility will never result in an 
organ so deformed as to require repair unless the operation has been 
unjustifiably severe. Strange to say, laceration of the cervix occurs 
not only during normal parturition at term, but also in consequence of 
the forcible expulsion of an ovum through the unprepared lower segment 
of the uterus at as early a period as two or three months. We have 
met with a number of cases of severe laceration of the cervix produced 
by such early abortions. Usually, laceration of the Cervix oocurs dur- 
ing the first confinement, each subsequent one more or less increasing 
the depth of the tear. [My case-books give, of 612 lacerations in 
parous women, 146 primiparse and 310 others in whom the symptoms 
dated from their first child.— P. F. M.] 

Pathology. — The first pathological result of a parturient laceration 
of the cervix is subinvolution of the uterus, either of the cervix alone 
or of the whole organ. Eventually, hyperplasia of the uterus follows 
the subinvolution, and the uterine adnexa, ovaries, tubes, ligaments, 
and cellular tissue take part in the process of defective involution and 
chronic hyperemia. We thus have relaxed ligaments, congested ova- 
ries and tubes, and oedematous cellular tissue. In course of time the 
heavy uterus drags on the lax ligaments, and a displacement occurs. 
The ovaries change their hyperemia to hyperplasia, and the slightest 
accidental impulse may light up an inflammatory process in the ovaries, 



PATHOLOGY. 347 

cellular tissue, or peritoneum. In some cases a firm, dense cicatrix covers 
the laceration and compresses terminal nerve-filaments, which by means 
of their communications with the spinal and sympathetic systems pro- 
duce reflex neuroses in the pelvis, down the thighs, along the back, and 
in different portions of the body. The relations between some of these 
neuroses and the laceration is often so mysterious as to be inexplica- 
ble, but numerous cases are on record in which the repair of the lacera- 
tion by a plastic operation has secured a cure of the neuroses. These 
neuroses may be either physical or mental. Emmet claims that gene- 
ral anaemia from defective innervation of the nutrient organs is one of 
the results of reflex neuroses from a lacerated cervix. 

If a lacerated cervix does not cicatrize over, its lips may undergo cys- 
tic or papillary hyperplasia or both ; the separated lips evert, the mucous 
membrane lining the cavity of the cervix is rolled out, its epithelium is 
gradually rubbed off, and a hyperplasia of the cysts and papillae of the 
exposed mucous membrane takes place. From this swollen, granulating 
surface oozes a profuse glairy discharge and slight traumatic hemorrhages 
are frequent. This hyperaemic and hyperplastic condition often extends 
upward to, and even beyond, the internal os, and cervical and corporeal 
endometritis result, in the latter affection frequently attended by the 
formation of fungosities. In consequence we have menorrhagia, which 
may become so profuse as to endanger the life of the patient. One 
other possible result of laceration of the cervix merits attention — 
namely, the tendency of the raw bleeding surface to undergo malig- 
nant degeneration. Breisky and Emmet have called attention to the 
frequency with which epithelioma of the cervix was found in conjunc- 
tion with a laceration of the lips of that part, and our own experience 
decidedly confirms their observations. Certainly, all these pathological 
conditions are sufficiently grave to give to laceration of the cervix a 
prominent place in the production of utero-pelvic disease. 

In a certain proportion of cases laceration of the cervix produces 
none of the symptoms above described. Quite recently, Noeggerath. 1 
who for years ignored the importance of this lesion in the production 
of pelvic disease, has published a lengthy paper in which he attempts 
to prove, from extensive statistics drawn from his own practice, that 
laceration of the cervix is of absolutely no consequence whatever: in 
fact, his conclusions seem to indicate that it was rather beneficial to the 
average woman under his care than otherwise. [Feeling that his deduc- 
tions were false, entirely unwarranted, and likely to place the subject 
in a wrong light, I induced my associate, Dr. B. H. Wells, 2 to tabulate 
a number of cases of laceration of the cervix from my own private 
case-books, the number being exactly double that used by Dr. Noegge- 
rath for his conclusions, and as a result, taking each of Dr. Noegge- 
rath's points up seriatim, Dr. Wells was able to prove that the conclu- 
sions of that writer were absolutely and positively incorrect and contrary 
to experience and logic. — P. F. M.] 

We may safely say at the present day that it is entirely futile for 
any one who honestly and dispassionately considers this subject to deny 

1 Meeting of German naturalists and physicians, Wiesbaden, Sept.. 1SS7. 

2 Am. Journ. Obstet., xxi., ,'>, March, 1888, p. 257. 



348 



LACERATION OF THE CERVIX UTERI. 



the pathological significance of laceration of the cervix in its aggra- 
vated forms as a factor in the production of utero-pelvic disease. We 
ourselves know of no one other special lesion of the uterus — excepting, 
of course, malignant disease — which in our own opinion and experience 
is so productive of evil consequences as this one, nor of none which it 
is so easy to cure by the appropriate treatment to be described later on. 
Frequency. — It may fairly be said that but few women are confined 
at term without sustaining some injury to the cervix, be it ever so 
slight. Goodell says that about one out of every six women suffering 
from uterine disease has an ununited laceration of the cervix. [I 
found among 2500 parous women (that is, those who had borne one or 
more children) 612 cases of well-marked laceration of the cervix, or 
about 25 per cent. Of these, only 280 were of sufficient depth to pro- 

Fig. 160. 





Fig. 159. 












^^ 


■jfe.'- • 






) 










Unilateral Laceration of Cervix. 1 



Bilateral Laceration of Cervix, First Degree. 



Fig. 161. 



duce symptoms and require treatment. The proportion of deeper rents, 
therefore, or of such as were likely to produce the pathological symp- 
toms already described, was less than 50 per cent. — P. F. M.] 

Varieties and Degrees. — The par- 
turient cervix uteri may be lacer- 
ated in one or several places and 
at any point of its circumference. 
The forms of laceration usually met 
with are the following : unilateral, 
bilateral, anterior, posterior, stellate, 
multiple. Of these, the bilateral is 
the most common, and takes place 
on either side of the cervix toward 
the lateral vaginal pouch. The uni- 
lateral is most common on the left 
side, probably in consequence of the 
predominance of the left occipito- 
anterior presentations. [The rela- 

Bilateral Laceration of Cervix, Second . • p r» r\ • , • i 

Degree. tive frequency of these varieties and 

1 All these figures of lacerated cervix are taken through Sims' s speculum, with the 
patient on her left side. 




PATHOLOGY. 



349 



degrees of laceration is as follows: Among the 612 cases mentioned, 
there were, bilateral, 340 ; unilateral, 120 (left 80, right 40) ; anterior, 7 ; 
posterior, 12 ; stellate, 11 ; remainder not noted. First degree, 272 ; 
second, 169; third or worst, 171.— P. F. M.] 

Pathological Changes in the Lacerated Cervix. — In consequence of 
the laceration subinvolution of the cervix takes place. The numerous 

Fig. 162. 



- 










f 
















! ^^^0^^m 












/j$mF®^ 




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;" j" " * -"$& 






?:•::;' 






Jfj» "* i ■ 






?'* 




fj 


' i "**^jfe 






W*£ "-% I: 










■ 






' ' ^•^^Bm''"^ ' '* 






! 






X \>L» ■Sf&^'"^ r "' 






# \ 






Cv "Ji^^m 












'V... 




.;_—•*■ 


^J^^ 






'■"-*•'• ." '^hv*^~?S^5 




8!P* 




H 







Bilateral Laceration of Cervix, Third Degree. 

The tenacula are inserted in the anterior and posterior lips to show how the lips can be brought together 
and the natural shape of the cervix restored. 

glands are closed and become distended with mucus and cause hyper- 
trophy of the Avhole organ ; the lips of the cervix roll out, the endo- 



Fig. 163. 



Fig. 164. 




Stellate Laceration of Cervix. 



Laceration of Cervix, with Cystic and Papillary 
Hyperplasia, simulating Epithelial Cancer. 
(From a case of Munde.) 



cervical mucous membrane is exposed, becomes eroded and ulcerated or 
frequently very much hypertrophied, and as a result a chronic cervical 
catarrh is excited which gives rise to a profuse, discolored, glairy dis- 



350 



LACERATION OF THE CERVIX UTERI. 





Fig. 165. 




; / 35J "Jm %/\ ' m 




\$L 






m f 


— ^^Lffm 


% ^ 


vTW?J EP^IB 


V 


Nv Hjjjjir v' .^'•'^P 


\ 


^te»^^ 




x^SP**^ 1 *- 



charge. This condition was formerly mistaken for ulceration, and is so 
described in nearly all the older books published before the true sig- 
nificance of the lesion was recognized by Emmet. We are of the 
opinion that in women who have borne children the larger proportion 
of cases of cervical endometritis are due to the laceration of that part 
and the pathological changes directly following. 

Symptoms. — The physical signs which may be present as the result 
of a laceration of the cervix are either local or general or both. 

Local. — Dull pain in the back, sa- 
crum, and lumbar region ; a sensation 
of weight, bearing down, or dragging in 
the pelvis ; pain in the ovarian regions, 
hips, and thighs ; leucorrhoea, chiefly 
of the cervico-uterine variety ; menor- 
rhagia, occasionally metrorrhagia, espe- 
cially after coition; dyspareunia, ster- 
ility, and habitual miscarriage. 

General. — The longer the laceration 
has existed, the greater its degree, the 
more marked the local symptoms, the 
more will the general health of the 
patient be affected, and in course of 
time a most decided state of anaemia, 
in consequence of which digestion suf- 
ers, and chronic invalidism will set in. 
The influence of the so-called cicatricial 
plug in the upper angle of the laceration as a factor in producing the 
general anaemia is insisted upon chiefly by Emmet, although many other 
gynecologists dispute the correctness of his views. While we have seen 
cases which decidedly confirm Emmet's theory, we are still not entirely 
converted to it, and are more inclined to attribute the improvement in 
the general health of such patients after trachelorrhaphy to moral influ- 
ences. Still, we would like to leave this question for the present 
unsettled. 

Diagnosis. — This may be made either by the touch, or by the specu- 
lum, or both. 

By the Touch. — It is hardly necessary to describe how a laceration 
of the cervix can be detected by the examining finger. Instead of the 
normal, pointed vaginal cervix with a small circular or transverse 
external os at its tip, the finger feels an open cavity with more or less 
separated lips, between which the index can be readily inserted, in 
extreme cases almost up to the internal os. In the angles of the rent 
the finger touches hardened tissue, pressure upon which produces pain, 
often radiating into the pelvis and down the respective thighs. Instead 
of being conical, the cervix in aggravated cases is broad, the everted 
lips completely filling the vaginal vault. 

Through the Speculum. — A more or less raw, bleeding surface is 
exposed to the eye, which naturally gives the impression of what was 
formerly believed to be ulceration of the os. Through the cylindrical 
or even the bivalve speculum the true character of the lesion is difficult 



Outline of wedge-shaped flaps excised 
in Trachelorrhaphy for areolar hy- 
perplasia of lacerated cervix : a, left 
angle ; b, right angle ; a c' c, left den- 
udation ; b d' d, right denudation ; 
c' and c, and d' and d are brought to- 
gether by sutures respectively. 



PROGNOSIS. 351 

to recognize, because the outer limits of the separated lips are not 
included in the lumen of the speculum ; but through a Sims speculum 
the whole cervix is freely exposed and the relations of the lips to each 
other made clear. The confirmation of the diagnosis attained by the 
finger and the eye is secured by means of two tenacula, one hooked into 
each lip, which on being approximated at once restore the lips to their 
normal position and the cervix to its natural shape. In this way it is 
easy to avoid mistaking a superficial erosion of the lips of the cervix 
for a laceration ; but it takes a practised examiner to distinguish 
between a lacerated cervix with cystic or papillary hyperplasia, and an 
erosion in a nullipara. 

Differential Diagnosis. — Besides the condition just mentioned, the 
only other which we know of as likely to be mistaken for something 
else than a lacerated cervix is that known as epithelioma ; and this 
mistake can be made only in cases where an excessive development of 
the glands and papillae of a lacerated cervix so closely simulates malig- 
nant disease that the diagnosis can only be settled by the microscope. 
Congenital malformation of the cervix simulating a laceration has been 
observed by Fischl of Prague in a still-born infant, and we [P. F. M.] 
have seen such a case in a virgin of sixteen years. 

Evil Results of Laceration. — The majority of the pathological con- 
ditions induced by laceration of the cervix have already been described, 
and w r e will merely re-enumerate them : subinvolution of the cervix or 
the whole uterus, cervical and corporeal endometritis, papillary and cys- 
tic hyperplasia of the cervix, uterine fungosities, menorrhagia, uterine 
displacements, chronic periuterine cellulitis and peritonitis, neuralgia of 
cervix, chronic ovaritis, and epithelioma. Two other conditions remain 
to be mentioned — namely, incapacity of conception or absolute sterility, 
and its converse, the tendency to abortion or virtual sterility. At first 
sight it may seem strange that these two conditions, sterility and a possi- 
bility of conception, should result from the same pathological process. 
On the one hand, the laceration forbids conception ; on the other, it 
permits it, or even facilitates it, by means of the unusual gaping of the 
cervical canal. But the explanation is easy when we consider the sub- 
sequent changes in the cervical cavity and their consequences. The 
thick, semi-purulent mucus indicative of cervical endometritis effectu- 
ally plugs the uterine canal against the entrance of spermatozoa, and 
therefore produces sterility ; besides, the purulent secretion may injure 
the vitality of the spermatozoa. But supposing this mucous plug to be 
temporarily removed, coition takes place, and conception follows ; the gap- 
ing internal os and the irritable uterine cavity, however, soon prove as 
efficient factors against the continuance of the pregnancy as the cervical 
plug in the first instance acted as an obstacle to its occurrence. Before 
the gestation has advanced to the third or fourth month the irritable 
uterus contracts and expels its contents, and thus in both eases sterility 
is the result. As an additional reason for sterility the pain produced 
by the act of coition may be mentioned, the male organ bruising and 
irritating the sensitive cervix. Of course there are numerous cases 
where women conceive readily and carry their children to term with 
lacerations of the cervix even of the most aggravated degree, but these 



352 LACERATION OF THE CERVIX UTERI 

cases merely emphasize the old adage that exception proves the 
rule. 

Prognosis. — Untreated, many cases of laceration of the cervix cica- 
trize over and become entirely insignificant, but the rule undoubtedly 
holds good that a lacerated cervix, if the lesion is of a major degree, 
will eventually produce some pathological result which will attract atten- 
tion to it and call for its relief. 

Significance. — We have already mentioned that Simpson, Gardner, 
and Roser preceded Dr. Emmet in their description of this accident ; 
but no one can dispute the claim of Dr. Thomas Addis Emmet to the 
first recognition of the true character, importance, and cure of laceration 
of the cervix. Undoubtedly, the true importance of this lesion has been 
exaggerated by many enthusiastic operators, chiefly such as were anx- 
ious to make names for themselves as gynecological surgeons, but at the 
present day, with few exceptions, the true significance of this condition 
is acknowledged by the large majority of fair-thinking and progressive 
gynecologists all over the world, and it is described in all of the promi- 
nent textbooks published during the last ten years. Our own convic- 
tion may be briefly stated in the following sentence : 

The significance of a cervical rent as a cause of uterine disease lies 
not in the existence of the rent itself, but solely in the symptoms which 
it produces and in the direct influence ivhich can be traced to it as the 
prime factor in the production or maintenance of some pathological 
condition or functional derangement in the pelvic organs or elsewhere 
in the body. 

What special condition of, or change in, the cervix produces such 
pathological results the gynecologist must seek to determine in each 
individual case. If careful examination fails to trace any relation 
between the cervical lesion and the objective signs, common sense will 
lead us to seek elsewhere than in the cervix for the primary cause. 
Thus a deep laceration with all the tissue-changes above described may 
occasionally produce no local or general symptoms whatever, and, on the 
other hand, a comparatively shallow cicatrized fissure may be the source 
of an ovarian, sciatic, or supraorbital neuralgia. From our experience 
we have come to the general conclusion that of all the women who have 
a lacerated cervix during confinement, one-half or 50 per cent, suffer no 
inconvenience whatever from the injury, either because it was slight and 
healed spontaneously, or because the involution was so complete as to 
reduce the originally complete rent to a comparatively trivial nick. Of 
the remaining 50 per cent., one-half or 25 per cent, of the whole number 
for a time present some of the symptoms above described, then gradually 
recover spontaneously or require palliative local treatment before they 
are relieved. Of the remaining 25 per cent., one-half may be curable 
by appropriate local treatment, but will eventually require the radical 
operation for a permanent cure, and the last half, or 12 J per cent, of 
the whole number, are absolutely incurable otherwise than by the radi- 
cal operation. It thus appears that we consider only one-half of all 
the lacerations of the cervix which occur as producing symptoms and 
requiring treatment of any kind, and of these but one-quarter, or 
one-eighth of all lacerations, as absolutely requiring Emmet's operation. 



TREATMENT. 353 

Surely we cannot be reproached with exaggerating the significance of 
the lesion or of the necessity for its operative treatment ! 

Treatment. — This may be divided into palliative and radical. 

Palliative Treatment. — By palliative treament are understood all 
the remedies which tend to relieve the local pathological conditions in 
the cervix, always excepting the laceration itself. Thus by it the hyper- 
emia is diminished, the cervical catarrh is cured, the cystic and papil- 
lary hyperplasia and the erosion of the everted lips are healed, the 
cicatrix is softened and reduced, and the reflex neuroses are relieved ; 
and secondarily, subinvolution and hyperplasia of the whole uterus, 
chronic ovarian congestion, and chronic pelvic inflammation are all bene- 
fited and perhaps entirely cured, and in addition the displacement of the 
uterus, the relaxation and prolapsus of the vaginal wall, and the chronic 
vaginal leucorrhoea are improved. It is evident, therefore, that treat- 
ment which does all this is by no means useless, and still the laceration 
of the cervix remains practically the same and improvement is but 
temporary. 

The remedies which are to be employed in this course of palliative 
treatment are the following : 1. Hot vaginal douches ; 2. Occasional 
scarification of the cervix ; 3. Painting the cervix and vaginal vault 
with tincture of iodine twice a week, followed by a tampon saturated 
with glycerin or a solution of boric acid in glycerin ; 4. Removal of 
the hypertrophied glands by the sharp curette, or their puncture and 
the application of nitric acid, iodized .phenol, or tincture of iodine ; 

5. The application of tannic acid, or tannin and iodoform equal parts, 
to the cervix two or three times a week, followed by a dry tampon; 

6. The introduction of a proper pessary if the uterus is displaced. 
This palliative tratment may occupy several months, and, as we have 

already said, is usually merely temporary in its results. In many cases 
the pathological changes referred to are such as to render an immediate 
operation for the repair of the laceration inadvisable, since primary 
union would probably not take place. The palliative treatment, there- 
fore, above described is indicated in such cases in order to prepare the 
organ for a successful radical operation. 

Indications for Trachelorrhaphy. — It is a difficult matter to lay 
down a strict indication for the radical operation of a lacerated cervix. 
The best general indication which we can formulate for this operation 
is similar to the conclusion given when speaking of the significance of 
the lesion — namely, the mere existence of a laceration of the cervix 
does not call for the radical operation; the indication for that measure 
depends entirely on the depth of the rent, on the degree of e version and 
the amount of erosion and hyperplasia of the torn lips, on the intensity 
of the symptoms unquestionably or probably depending on it. and on the 
improbability of these symptoms being permanently cured by other than 
radical treatment. 

[In an article in the January (1870) number of the American Journal 

of Obstetrics on " The Indications for Hystero-Trachelorrhaphy " I specified 

a few indications for the operation, which F will briefly enumerate here as 

additions to or modifications of those already mentioned : 1. Slight lacera- 

23 



354 LACERATION OF THE CERVIX UTERI 

tions, with persistent profuse cervical leucorrhoea. 2. Slight lacerations in 
subinvoluted or hyperplastic uteri where trachelorrhaphy is expected rather 
to reduce the size of the uterus than merely to cure the rent. 3. Hyper- 
plastic or cystic ectropium of one lip. Here the enlarged lip is simply 
excised and the raw edges are brought together by sutures. 4. Laceration 
of the cervical wall of greater or lesser depth, not extending to or through 
the lips of the os ; the result is a gaping os and a dilated, paralyzed cervix. 
By slitting the lips bilaterally up to the vaginal vault, trimming off diseased 
mucous membrane, and sewing together the raw surfaces a speedy cure can 
be achieved. 5. Erosions, catarrhal, granular, and follicular, of the cervix 
found in nulliparae, which are well known to be exceedingly obstinate to 
the usual caustic and astringent treatment. By trimming off the eroded 
surface and uniting its edges with sutures a much more rapid and certain cure 
can be attained than by the old methods. (For colored plates illustrating the 
various degrees and forms of laceration I would refer to the article men- 
tioned.)— P. F. M.] 

Operation. — While the operation for the repair of a lacerated cervix 
is neither a serious nor dangerous surgical procedure, it nevertheless 
requires more technical skill and dexterity than any other gynecological 
operation, and the instruments necessary for it should be in every way 
the best to be procured. The following instruments are necessary : 

A broad, short, flat Sims speculum ; 

A depressor with wooden handle ; 

Two solid steel tenacula ; 

Two Emmet's small curved cervix scissors, right and left ; 

One Emmet's stout needle-holder ; 

One Munde's counter-pressure hook ; 

One Emmet's twisting forceps ; 

One Sims's shield ; 

One pair of stout wire scissors ; 

Six Schnetter's cervix needles, long and medium, curved, and 
straight. 

Six Sims's or Hanks's cervix needles ; 

Braided silk, medium size ; 

Pure silver wire, No. 27, several coils ; 

Six metal sponge-holders ; 

Fine graded cheap sponges, to be cut into suitable pieces ; 

One Simpson's sound. 

[I generally operate through my flanged Sims's speculum. — P. F. M.] 

Assistants. — Four assistants are needed, two of whom — the one in 
charge of the ether, and the one to hand instruments and thread nee- 
dles — must be physicians ; the other two can be nurses, one of whom 
holds the speculum and the other washes and hands the sponges. 

Preparation of the Patient. — The usual rules to be observed before 
every operation on the female pelvic organs apply also in this case. 
The bowels have been thoroughly moved, the meal preceding the ope- 
ration is omitted ; a copious hot vaginal douche has been given just 
before the hour fixed for the operation, and the patient is dressed sim- 
ply in her night-clothes. We usually give an anaesthetic, although we 



TREATMENT. 



355 



have performed the operation a number of times without it in cases 
where cardiac or pulmonary disease contraindicated the use of anaes- 
thesia or the patient absolutely refused to take it. The cervix is not 
so very sensitive but that a patient of ordinary fortitude can stand the 
pain of this operation ; still, we prefer the anaesthetic unless there are 
excellent reasons for omitting it. The operation is performed through 
a Sims's speculum, with the patient in the left latero-abdominal posi- 
tion. The operator first seizes the anterior lip of the cervix with a 
tenaculum, and pares the lower or left half of this lip down to the 
angle in the median line, and carries the denudation over a correspond- 
ing surface on the posterior lip, endeavoring to make the two denuded 
areas as nearly alike as possible. He then repeats the same procedure 
on the upper or right portion of the lacerated cervix, leaving a strip 
about a quarter of an inch wide of denuded tissue on each lip of the 
cervix for the future external os and cervical canal. (See Figs. 165 and 
166.) If troublesome bleeding 

occurs during this procedure, a Fig. 166. 

deep wire stitch may at once 
be passed through both lips 
of the cervix above the angle 
and twisted, which will com- 
press the circular artery and 
effectually stop the bleeding. 
Having trimmed off the flaps 
thus described, the lips of the 
cervix should be brought in 
apposition by two tenacula in 
order to see whether they can easily be approximated by the sutures. 
All retention-cysts — so-called ovula Nabothi — which appear on the 
surface of the wound should be carefully excised, as they interfere 
with union. The sutures are then introduced, the first being passed 
through the upper angle of the rent, and each successive one through 
the whole depth of each lip until all the sutures needed for the upper or 
right half of the tear have 

been inserted ; then the Fig. 167. 

stitches for the lower or 
left portion of the rent 
are inserted, beginning 
again with the angle. 
The stitches of the upper 
portion of the rent are 
first twisted, the ends be- 
in«; bent down against the 
anterior lip and cut off 
short, so as not to injure 
the anterior vaginal wall. 
(See Figs. 167 and 168.) 
In forcing the needle 

through the lips of the cervix, chiefly the posterior, the counterpres- 
sure-hook (see Fig. 119) will be found of great service. From two to 




Area of Denudation in Trachelorrhaphy. 




Introduction oi 



356 



LACERATION OF THE CERVIX UTERI. 



Fig. 168. 




Sutures Twisted and Cut Short after 
Trachelorrhaphy. 



four stitches will usually be needed for each side of the tear. Care 

should be taken not to twist the sutures 
too tight, to avoid puckering between 
them, and if the tissues appear blanched 
to loosen them before leaving the patient. 
The operation may last in easy cases but 
fifteen minutes, but often may occupy 
thirty minutes or more. After it is fin- 
ished the vagina is irrigated with a hot 
douche of 1 : 5000 corrosive sublimate, an 
aseptic pad is put over the vulva, and the 
patient placed in bed. We usually keep 
an ice-bag over the suprapubic region for 
twenty-four hours as a guard against pos- 
sible inflammatory reaction. If it was 
found necessary to remove all the mucous 
surface from both lips, or to scrape the 
cervical cavity with the curette, and con- 
traction of the external os is thus to be 
apprehended, a glass or hard-rubber stem 
may be inserted, and kept in situ for a week by a tampon of iodo- 
form gauze. 

The patient is allowed to pass urine herself, even to the extent of 
letting her sit upon the vessel if necessary, but if she is unable to 
relieve herself in this manner the catheter must, of course, be used. 
She is kept in bed for at least a week, probably nearer two, a tepid 2 
per cent, earbolized vaginal douche being given once or twice daily if 
there is any discharge. 

[Formerly I was in the habit of removing the sutures about the seventh 
or tenth day ; but. having witnessed several instances where the apparently 
perfectly united lips separated again immediately after the withdrawal of the 
stitches, I have for several years followed the plan of leaving them in for 
three weeks or longer, allowing the patient to get up and walk about, and 
even come to my office for the removal of the stitches. If menstruation 
came on. as would probably be the case between the second and third weeks 
after the operation, the stitches were allowed to remain until the flow had 
ceased. Since I have adopted this plan I have found more satisfactory and 
firmer union than when I removed the stitches as early as was formerly my 
practice. — P. F. M.] 

The bowels should be kept regular after the operation by mild laxa- 
tives or enemas. Usually there is very little pain following this opera- 
tion, and unpleasant consequences need scarcely be anticipated. Of 
late, if there was a displacement present, usually a retroversion, we 
have been in the habit of replacing the uterus immediately after the 
operation and inserting a pessary, which we allowed to remain until the 
stitches Avere removed and perhaps longer, and have not found it to 
interfere in any way with the healing of the wound. 

Results achieved by Trachelorraphy. — Of course, not every disease 
that female flesh is heir to is due to a laceration of the cervix uteri and 
is curable by repair of that lesion, but we can confidently assert that 



TREATMENT. 357 

we have many times seen the following conditions relieved and cured 
by this operation : Subinvolution and hyperplasia of the cervix and of 
the whole uterus, the organ diminishing from three and a half to two 
and a half inches within several months after ; cervical and corporeal 
endometritis ; monorrhagia, provided curetting of the endometrium pre- 
ceded the repair of the lacerated cervix ; chronic ovarian congestion ; 
reflex neuroses ; general anaemia. As regards the influence of the 
operation on sterility, we are not willing to claim that it cures this con- 
dition with any degree of certainty ; still, we have seen many cases where 
conception followed the operation so rapidly as to lead us to believe that 
the removal of the diseased condition of the cervical canal had a large 
influence in favoring that occurrence. Certainly the operation does 
not prevent conception, except when the operator has done his work 
too well and closed the external os so tightly as to prevent the entrance 
of spermatozoa. 

Dangers of the Operation. — Although ordinarily trachelorrhaphy is 
neither a serious nor dangerous operation, still, our own experience and 
that of a number of perfectly competent operators obliges us to say 
that at times it may be attended and followed by serious complications, 
which in a few instances have even resulted in death. Dr. B. Hughes 
Wells investigated the subject at our instigation some years ago, 1 with 
the result that he found reported 43 cases of pelvic inflammation (34 
cellulitis, 9 peritonitis) with 6 deaths occurring in the practice of Drs. 
Hunter (4 with 1 death), Goodell (7 with 3 deaths), Mann (3), Munde 
(4 with 2 deaths), Emmet (1), Reamy (6), Jackson (3), and some others. 
The cause of death in all cases was general peritonitis. [I have seen 
three cases of very severe secondary hemorrhage following the opera- 
tion, probably due to the cutting of a deep branch of the circular 
artery by one of the stitches ; only the introduction of deeper sutures 
succeeded in arresting the bleeding. Emmet, Pallen, and Goodell 
each report a similar experience. — P. F. M.] 

Occasionally the operation fails, either in consequence of the fault 
of the operator, who has introduced too many stitches or has twisted 
them too tightly or has omitted some surgical precaution, or in conse- 
quence of poor general health of the patient. Wells's statistics show 
637 operations with 44 failures, or about 6.9 per cent. 

Of course a subsequent labor, especially if conception soon follows 
the operation, may result in a relaceration, but this is no more the case 
than during any first confinement. Wells's statistics show that of the 
77 cases where the condition of the cervix was noted after labor follow- 
ing the operation, 62, or 80 per cent., were not relacerated, while of 
the remaining 15, 8 were but slightly torn. 

The question is so often asked us, What will result if a lacerated 
cervix which we have pronounced as requiring operation is not repaired ? 
that it is worth while for us to say that in the majority of instances no 
danger to health is likely to result from the non-performance of the 
operation. The patient will merely continue in the condition of inva- 
lidism for the relief of which she applied to us until the arrival o\' the 
menopause, when probably her symptoms will gradually subside. 

1 See American Journ. Obstet., June. 1884. 



358 DISPLACEMENTS OF THE UTERUS. 

Whether it is worth her while to live so many years of discomfort and 
misery, when she could be easily and safely relieved by a comparatively 
trifling operation, is for her to decide. One further danger which such 
patients run we have already referred to — namely, the undoubted tend- 
ency of a lacerated, eroded, and hyperplastic cervix to undergo malig- 
nant degeneration. Having pointed out this risk to the patient, our 
duty is accomplished. 

Occasionally a severe laceration heals spontaneously, but it is impos- 
sible to foretell when that is likely to occur. 



CHAPTER XXVII. 
GENERAL CONSIDERATIONS ON DISPLACEMENTS OF THE UTERUS. 

History. — That the earliest practitioners of medicine were familiar 
with this subject is abundantly attested by the writings of the Greek 
and Roman schools. It is distinctly mentioned by Hippocrates, and 
more clearly and exactly still by Galen and Moschion about the second 
century of the Christian era. This remark applies not only to pro- 
lapse, but also to versions, which were evidently understood. Hippoc- 
rates and Moschion even described latero-version, a variety which 
has not been much noticed by modern writers, and Aetius 1 in the sixth 
century indicates the method for reduction and retention in place of the 
retro verted womb. Although certain passages in the works of these 
old writers seem obscurely to refer to bending of the uterus upon 
itself — such, for example, as one in which Hippocrates speaks of cases 
in which " uterorum os conclusion, aut contortum fuerit" — there is no 
satisfactory evidence that they understood the difference between ver- 
sions and flexions. 

Passing over many centuries, at the middle of the eighteenth we find 
gynecologists paying attention to versions, and even to flexions, of the 
pregnant uterus, but losing sight of these displacements in the non- 
pregnant organ. Versions were at that period described by Gart- 
shore, W. Hunter, Jahn, and Desgranges, and flexions by Saxtorph, 
Wiltczek, Baudelocque, and Boer. Gartshore describes a case of retro- 
flexion complicated by retroversion, but the flexion appears to have 
made little impression upon him. In 1775, Saxtorph wrote an essay 
entitled De Ischuria ex utero retroflexo, describing a case with autopsy, 
but the words " orificium alte supra pubem reperi " show that it was 
not a true case. About the same time Wiltczek published an unques- 
tionable case " de utero retroflexo," but it occurred during utero-gesta- 
tion, and hence does not concern our inquiry. Both in England and 
France the subject of displacements attracted great attention at this 
period. " At this time Chopart upon his return from England, where 
he became well acquainted with W. Hunter, informed the Academy of 

1 Tetrabiblos, ch. lxxvii. 



VERSIONS AND FLEXIONS. 359 

Surgery what progress was being made in a subject which had attracted 
attention in France thirty years before." 1 

Denman was the first writer who described flexion of the non-preg- 
nant uterus, which he did in reference to a case of retroflexion about 
the year 1800. The wanting link, the description of anterior flexure, 
was not supplied until M. Ameline of France described anteflexions in 
1827. After this many others added to the knowledge of the subject, 
which soon assumed its place in systematic medical literature. A great 
deal was done for it by the introduction of the uterine sound as a 
means of diagnosis and of reposition. 

In carefully perusing more modern literature with reference to its 
contributions to uterine flexions, we are impressed with the belief that 
we are indebted to none more fully than to Cusco, whose very valuable 
thesis we have alluded to, and Graily Hewitt, whose views are familiar 
to all. 

In this country the profession is generally indebted for correct views 
upon the subject to Dewees, Meigs, and Hodge. More especially has 
the last of these identified his name with it by important contributions 
to pathology and treatment. 

Pathologicul Significance of Versions and Flexions. — The ancients 
ascribe to these displacements many constitutional evils, as paralysis, 
hysteria, etc., and even until a very recent period they were credited 
with a great deal of pelvic pain and functional uterine disturbance 
which it was supposed almost universally attended them. Until 1854 
this belief prevailed very generally, having the powerful support and 
endorsement of such men as Velpeau, Simpson, and Valleix. It is 
true that it was contested by Cruveilhier and Dubois 2 before the period 
mentioned ; but at that time a spirited discussion arose concerning it 
in the Academy of Medicine of Paris, which not only threw much 
doubt upon it, but gave rise to a powerful opposition, in the ranks of 
which appeared Depaul, H. Bennet, Aran, Becquerel, and others equally 
eminent. They maintained that these displacements of the womb, if 
unaccompanied by textural lesion, produced no constitutional disturbance, 
created, as a rule, no discomfort, and did not deserve the attention in 
treatment which had been bestowed upon them. They did not believe 
that the dislocation was the cause of suffering when this existed alone, 
but looked upon it in such cases as an epiphenomenon engrafted upon 
some important lesion. Consequently, they were opposed to reliance 
being placed upon support by pessaries as one of the essentials of treat- 
ment, as had been done by the other school. 

When views supposed to be false are repudiated, those adopting new 
ones are always apt to run too far into an opposite extreme, and in this 
instance many have done so. Scanzoni 3 sounds the keynote of this 
extreme party when he states that " flexions of the womb do not acquire 
any importance, nor are followed by any serious dangers, save when 
they are complicated with an alteration in the texture of the organ." 

The following propositions present the views upon this subject which 
we think will be found to bear the test of experience : 

1 Cusco, TJiese de V Anteflexion et de la Retroflexion de I' lMrus } Paris, 185;}. 

2 Goupil, B. & G., op. ciL, p. 459. s Gp. e&, Amor, ed., \\ 112. 



360 DISPLACEMENTS OF THE UTERUS. 

1st. Versions and flexions of the womb may, and not unfrequently 
do, exist without causing any symptoms, for in themselves they do not 
constitute disease. Thus it is that occasionally we see the uterus forced 
completely out of its place without the production of morbid signs. 

2d. By interfering with escape of menstrual blood, by disordering 
uterine circulation and keeping up hyperemia, by causing pressure and 
friction from contact with surrounding parts, and by creating a barrier 
to the entrance of seminal fluid, they become, as a general rule, of great 
importance and require special attention. 

3d. Often being the results, as they are sometimes the causes, of 
uterine and peri-uterine diseases, their treatment should be combined 
with efforts at the alleviation of these states. 

4th. Treatment by pessaries, combined with means which remove 
the weight of the superincumbent intestines, is of great value. By it, 
even although the primary disease is not affected, we may relieve one 
of its most troublesome symptoms, which often reacts for evil in aggra- 
vating and prolonging the affection which caused it. When the dis- 
placement has resulted from relaxation of the uterine ligaments in con- 
sequence of increased weight or pressure from the abdominal viscera, 
pessaries prove a most useful and efficient means of treatment. 

5th. One reason for the great prejudice existing against the use of 
pessaries in the minds of many is to be found in the fact that most of 
the enlargements of the uterus were attributed unhesitatingly to paren- 
chymatous inflammation. Mechanically lifting an inflamed organ ap- 
peared repulsive to reason. So long as the existing inflammation was 
uncured, efforts appeared to be directed to a side issue, a result and not 
the root of the disorder. Since it is now known that what was sup- 
posed to be chronic metritis is really a vice of nutrition resulting in 
new formation of connective tissue, this theoretical objection falls to 
the ground. 

6th. Another reason is this : it requires skill and ingenuity, the 
result of practice, not only to do good with pessaries, but to apply them 
without doing absolute harm. In the hands of a physician who has 
made no special, or at least careful, study of their use, and who habit- 
ually applies only a half dozen in the course of every year, pessaries 
are elements of absolute danger. It would be as unreasonable to expect 
an untaught experimentor to fit the foot comfortably with a shoe as to 
hope for efficiency, comfort, and safety from a pessary applied by igno- 
rant hands. 

7th. The gynecologist who to-day assumes the position that pessaries 
are useless or worse, and treats uterine displacements without their aid, 
will fail, by reason of the absence of other means to accomplish the 
existing indications, to meet the requirements of his cases. 

8th. A version, flexion, or prolapsus of the uterus being found on 
examination, which neither gives rise to present inconvenience nor 
causes the symptoms for the relief of which medical advice was sought, 
should nevertheless, if of one of the major degrees, be rectified if pos- 
sible, on the general principle that a displaced or distorted organ is 
pathological, and may sooner or later cause serious trouble. 

This rule, let it be distinctly understood, does not necessarily apply 



ANATOMY. 361 

to virgins or to women beyond the menopause, and under no circum- 
stances should it embrace cases where the treatment is likely to prove 
worse than the disease. 

Definition and Synonyms. — The term displacement is applied to any 
decided removal of the uterus from its normal position, without reference 
to the direction in which it has been moved. 

Anatomy. — One of the salient points in the comprehension of this 
most important subject consists in a clear understanding of the natural 
position of the healthy uterus. But, unfortunately, owing to the fact 
that the position of this organ varies constantly with inspiration and 
expiration, with muscular effort and quietude, and with fulness and 
emptiness of the bladder and rectum, it is difficult to arrive at common 
ground with reference to a point apparently so easy of settlement. As 
this chapter progresses we propose to put before the reader a diagram 
of the normal position of the uterus when not influenced by any decided 
disturbing cause. It is the result of long and careful investigation, 
and represents the truth, we think, more accurately than any other with 
which we are acquainted. 

Let any one examine a healthy uterus by means of Sims's speculum, 
and he will recognize that it is delicately and perfectly poised near the 
middle of the pelvic cavity by such supporting influences that it is 
never, even for a few seconds, perfectly at rest. It ascends with expi- 
ration and descends with inspiration with such regularity and distinct- 
ness that one operating upon the pelvic viscera can, by this up-and- 
down movement, recognize at once when an anaesthetic is affecting 
respiration badly. Under the influence of more decided factors, such 
as pregnancy, repletion of bladder or rectum, or violent muscular 
efforts, still more marked changes of position occur to it. Neverthe- 
less, we must agree upon a medium position as the normal one for a 
healthy uterus. 

The mechanical influences which sustain the uterus and preserve its 
pelvic equipoise are five in number. These are — 

1st. The retentive power of the abdominal cavity ; 

2d. The attachments to the areolar tissue of the pelvis ; 

3d. The juxtaposition of the other organs ; 

4th. The following ligaments : 

a. The round ligaments, continuations of uterine tissue, extending from 

uterine horns to labia majora ; 

b. The utero-vesical ligaments, bands of pelvic fascia, and uterine mus- 

cular tissue passing between the bladder and the cervico-cor- 
poreal junction, where they attach themselves and prevent 
retreat of cervix ; 

c. The utero-sacral ligaments, formed of hypogastric fascia and the 

uterine and vaginal tissue, extending from posterior surface of 
cervix, passing backward to be attached to sacrum, and pre- 
venting passage of cervix forward ; 

d. The broad ligaments, folds of peritoneum enclosing areolar tissue, 

ovarian and round ligaments, and ovaries, preventing lateral, 
anterior, and posterior displacements. 
None of these means of suspension are concerned in flexions and 



36: 



DISPLACEMENTS OF THE UTERUS 



inversions. which are combated by forces of an entirely different nature. 
The tissue of the normal, unimpregnated uterus is of such strong, resist- 
ing character in the adult female as to prevent too ^reat a curvature 
of the body upon the neck, either anteriorly, laterallv. 01 posteriorly. 
I: is to this peculiarity : cincture that immunity from these conditions 
is lue. 

When stimulate" Tenancy the uterine tissue dev-r. pe rapidly 

intt muscular structure. This keeps the cavity of the organ closed bV 
tonic contraction, and removes the possibility of inversion unless it be 
accomplished by absolute violence. But when from anv cause this 
contractile power is lestroyed and the condition of tone is : placed bv 
one ::' atony. flexion hi inversion mav occur. 



Fig. 169. 




The retentr re >wer of the abdomen is me :: the most important 
influences for the support of the uterus, and one of the most neglected 
in consideration of this subject. Fig. 169 represents the abdominal 
viscera in their normal condition and place. The diaphragm, one of 
:ir muscles most essential to respiration, is located nearly niidw in 
the trunk, across which it extends like a concavo-convex curtain. " Its 
action exactly resembles that of a piston in the cylinder of a pump."' 1 
As it contracts it forces the abdominal viscera downward directly 

- Om ■:-: :/ Lectures on Physiology, by Pre:. Kuse : University of Srrassburg. p. 294. 



ANATOMY. 



0£0 



it relaxes 



and expiration 
Fig. 170. 



occurs, the 




Normal Relations of the Female Pelvic Organs 
(diagrammatic). 



those of the pelvis, and, as 
depressed abdominal viscera 
rise to their former place, 
drawing the pelvic viscera 
upward. This up-and-down 
movement not only keeps the 
uterus in place, but it exerts 
a powerful stimulating influ- 
ence upon its circulation, and 
prevents that tendency to slug- 
gishness which perfect quie- 
tude so markedly favors. In 
our mind the importance of 
this subject cannot be over- 
estimated, for we believe that 
more valuable contributions to 
the etiology of uterine displace- 
ments in the future will come 
from investigations in this di- 
rection than any other. 

Fig. 170 represents the re- 
sults of our experience as to 
the normal position of the 
uterus, the bladder and rec- 
tum not being entirely empty. 

We shall allude in detail here to only one other factor in uterine support. 
The cervix will be observed to 
impinge slightly upon the ante- 
rior rectal wall, and to depress 
it a little. This a rectal exami- 
nation will usually reveal as 
the rule. The perineal body 
being normal, the posterior 
vaginal wall will from this 
point be found, upon careful 
vaginal touch, to rise up below 
the cervix, which will thus rest 
in a very shallow well or de- 
pression, the anterior cervical 
wall being supported, as if 
by a shelf, by the anterior 
projection of this. This an- 
terior projection of the pos- 
terior vaginal wall may be 
called the vaginal promon- 
tory, which possibly may pre- 
sent an obstacle to a descent 
of the cervix backward. It 
must be borne in mind that 
the support of the uterus is not 




accomplished by one or two powerful 



364 



DISPLACEMENTS OF THE UTERUS. 



factors alone, but by a combination of several, each working toward a 
common end. 

This very fact makes it manifest that a number of mechanical influ- 



Fig. 172. 




Pelvic Organs with Distended Rectum. 

ences may force an organ thus sustained upward, downward, laterally, 
or even bend it upon itself or turn it completely inside out, and that 
the direction of the impelling force or nature of the loss of support will 
determine the character of the displacement. The displacements which 
may thus result have received the following appellations : 

Ascent ; 

Descent or prolapsus ; 

Anteversion : 

Anteflexion ; 

Retroversion ; 

Retroflexion ; 

Retroposition with anteflexion ; 

Latero-version ; 

Latero-flexion ; 

Inversion. 
Having said this much in a general way as to displacements, let us 
say a few words with special reference to uterine flexions. 

Version, or turning of the uterus, signifies the fact that its long axis 
has changed its normal direction in the pelvis. Flexion signifies the 
bending of the uterus upon itself, so that a decided angle is created in 
its long axis. One condition is a displacement, the other a deformity 
in the organ. One may be likened to a dislocation of one of the long 



ANATOMY. 365 

bones, the other to a fracture with angular union of the broken extrem- 
ities. The treatment of one involves merely restoration of a dislocated 
organ ; that of the other rectification of a deformity which may have 
lasted for years or may even have been congenital. 

Frequency. — Flexions of the uterus — that is, displacements ante- 
riorly, posteriorly, or laterally — in which the decidedly predominating 
feature is flexion and not version, are very common : 

In 339 displacements Nonat found 67 flexions. 
" 84 " Meadows " 54 

" 895 " Munde " 337 

As to the relative frequency of anterior and posterior flexions, the 
evidence is decidedly in favor of the former : 

In 67 cases of flexion Nonat J found 33 anteflexions and 14 retroflexions. 
" 54 " " Meadows 2 " 20 " and 34 

" 54 " " Scanzoni 3 " 46 " and 8 

" 23 " " Valleix 4 "11 " and 12 

"296 " " Hewitt 5 " 184 " and 112 

Out of 1670 cases of flexion collected by Ludwig Joseph 6 of Bres- 
lau, 1100 were anterior and 570 posterior. Out of 345 cases of flexion, 
Emmet 7 found 273 to be anteflexion, 29 to be retroflexion, and 43 to 
be lateroflexion. In 337 cases of flexion Munde 8 reports 295 ante- 
flexions, 33 retroflexions, and 10 lateroflexions. 

Although the results are somewhat conflicting, the preponderance 
of evidence very decidedly favors anteflexion over retroflexion. 

One reason why we should anticipate that retroflexion would be less 
frequent than anteflexion is that the natural anterior obliquity of the 
uterus favors the latter and opposes the former displacement. Another 
is the fact that the former is more thoroughly guarded against by liga- 
mentous support, the round ligaments, running as they do from the 
horns of the uterus to the vulva, decidedly tending to prevent its occur- 
rence. Not only do they do this : the uterus, being kept by them in 
anterior inclination, should softening of its structure occur or any direct 
force be exerted upon it, naturally bends forward. 

If this be so, it may be asked why areolar hyperplasia so frequently 
results in retroflexion as well as in anteflexion. One reason is because 
the first effect of the increased uterine weight attending that disease is 
descent of the uterus. This relaxes the round ligaments, tends to bring 
the uterine axis in coincidence with that of the middle of the pelvis, 
and favors retroflexion. For a time the tendency is to descent and 
coincident retroversion. This continues until the progress of the cer- 
vix is checked by the utero-sacral ligaments. Then the heavy body 
bends, the weakened tissue yielding at the os internum, and retroflexion 
results. Another reason is that flexion commonly follows parturition. 

! Mai. de V Uterus, p. 416. 2 Am. Journ. ObsteL, vol. i. p. 176. 

3 Klob, .op. cit, p. 69. 4 Cusco, T/nV. p. 35. 

5 Dis. of Women, 2d Am. ed., p. 213. Hewitt includes versions with flexions. The 
other statistics refer to pure flexion. 

6 Berlin. Beitrage zur Geburtshulfe md Gynakologie, vol. ii. part '2, 1878. 

7 Prhi. and Prac. of Gynecology. 

8 "The Curability of Uterine Displacements," Am, Journ. Obstet.. Oct, 1881. 



366 DISPLACEMENTS OF THE UTERUS. 

at which time, attacking an organ with weakened tissues and relaxed 
ligaments, it meets with an efficient ally in the nurse, who favors retro- 
flexion at the expense of anteflexion by zealously forcing the fundus 
backward by a tight obstetric bandage. 

Thanks to the researches of Coste, Pouchet, Bischoff, and others, 
we are to-day well informed concerning the development of the uterus. 
Early in embryonic life a little duct shoots out from the external sur- 
face of each Wolffian body. These pass downward to unite and make 
a common canal, which becomes in time separated into uterus and 
vagina. Very soon a constriction appears, the neck of the uterus is 
formed, and becomes well developed, while a very small spot marks the 
point where the body is to show itself. The original canals become 
Fallopian tubes, and at the time of birth these, as well as the neck and 
body of the uterus, vagina, and other organs, have arrived at maturity. 
But it must not be supposed that the proportions of the adult uterus 
exist in that of infancy. The neck forms three-quarters of the organ, 
and the body, represented by a soft movable membrane, has no fixed 
position, but follows the bladder if upon opening the abdomen it is 
drawn forward, or the rectum if that viscus is pushed backward. Later 
in the life of the girl, even after she has reached puberty and men- 
struation has occurred, the uterus is curved forward ; and this anterior 
inflexion lasts through life if a normal state continue, though it is gen- 
erally diminished and sometimes overcome by puberty and utero-ges- 
tation. 

In 1849, Yelpeau, whose insight into gynecology was certainly 
remarkable, in a discussion before the Academy of Medicine of Paris 
declared that he had so often found an anterior inflexion of the uterus 
in healthy women that he was inclined to look upon it as normal. Upon 
this hint two of his pupils, Boullard (1852) and Piachaud (1853), with 
great assiduity investigated the subject, and determined that it is so in 
the child and virgin ; the latter basing his deductions upon 107 cases. 
Boullard found it to exist in 80 female foetuses and in 27 adult females. 
Verneuil and Follin subsequently confirmed these observations. 

That this is the normal condition up to puberty is unquestionable, 
nor can it be denied that to a limited degree it is so even afterward in 
the unmarried female. But, as Cusco has pointed out, it greatly dimin- 
ishes at puberty unless abnormal flexion is developed. Up to this time 
the neck of the uterus represents three-quarters of its entire bulk, and 
the whole organ is an insignificant element of the human body. At 
this time, however, it becomes an important organ. The body devel- 
ops ; its walls become thick, dense, and strong; "and," says Cusco, 
''this is an important point : if the development is regular its walls 
establish an equilibrium ; the uterus straightens itself; its anterior con- 
cavity disappears ; and there remains only a slight depression corre- 
sponding to the bladder." Up to this period of life curvature is unques- 
tionably due to the want of tone and power which characterizes unde- 
veloped uterine tissue, for even when anteflexion does not exist the 
organ is generally otherwise displaced. Thus, M. Soudry 1 in 71 post- 
mortem examinations of infants found the uterus anteflexed 41 times, 

1 Aran. op. cit, p. 981. 



ANATOMY. 

Fig. 173. 



367 




Normal Position of the Virgin Uterus (Schultze). 



Fig. 174. 




Normal Position of the Uterus in a Parous Woman vSehultze). 



368 DISPLACEMENTS OF THE UTERUS. 

anteverted 11 times, retroverted 15 times, retroflexed twice, and retro- 
verted with anteflexion twice. According to Winckel. 1 who substan- 
tially follows B. S. Schultze's 2 views on- uterine displacements, our 
present knowledge of the normal position of the uterus may be sum- 
marized as follows : "When the bladder and rectum are empty, the virgin 
uterus lies with its fundus behind the symphysis pubis, the os uteri, 
about 2 centimetres (4- inch) anterior to the sacral promontory, and the 
vagina and cervix forming nearly a right angle (Fig. 173). while in 
the parous woman the angle is acute. In the erect posture the long 
axis of the uterus is. therefore, almost horizontal (Fig. 174). The 
whole organ is also somewhat twisted, the vaginal portion toward the 
left, and the fundus toward the right hand. Our observations do not 
permit us to agree with the conclusions of Schultze and Winckel, which 
Fritsch also accepts. 3 We think the anteverted position of the uterus 
which they consider normal to be decidedly exaggerated, and have 
given our idea of the normal relation of the female pelvic organs in 
Fig. 170. Still, we will retain the statement, from the evidence at 
present upon record — 

1st. That anteflexion is the rule during early childhood : 

2d. That it is quite frequent, in slight degree, in nulliparous 
women, without constituting disease. 

For the prevention of versions certain pelvic ligaments are very 
effectual, but they have no power to prevent bending of the uterus 
upon itself. This is accomplished by the inherent strength and resist- 
ance of the proper tissue of the organ. Remove a normal uterus from 
the cadaver, balance it upon the cervix, and it will sustain itself per- 
fectly ; press it down by applying force to the fundus, and its own 
resiliency will cause it to erect itself immediately. Suppose a uterus 
to be composed of gutta-percha instead of living tissue : the material 
forming the walls of the neck will support the fundus when the pear- 
shaped bag is held by the stem or narrow part. To carry the simile 
further, so long as the proper tissue of the stem or neck remains nor- 
mally strong, flexion will be impossible unless its resistance be over- 
come by direct physical force exerted by pressure or traction. But if 
some influence be brought to bear locally, so as to soften the part sus- 
taining the fundus, it is evident that, as the gutta-percha walls grow 
weak, there may be a flexion of the fundus from its own weight. It 
will be said that these views represent the uterus as supported by the 
vagina, and leave out of consideration the broad ligaments which sus- 
tain the fundus. If these ligaments were tightly-drawn cords, we could 
admit their action, but as they are merely lax folds, which are not made 
tense by the bending of the uterus upon itself, we do not do so. 

A corroboration of this view is found in the frequency of flexions in 
the uteri of the aged which have lost tone and strength. "In aged 
women." says Klob. 4 "with exceedingly relaxed uteri, the pressure of 
the intestines upon the posterior surface of the organ is sufficient to 
cause anteflexion." 

1 Diseases of Women, authorized translation. Philada., 1889. 

2 Schultze, Die Pathologie und Therapie der Lageveranderungen der Gebarmutter, 1881. 

3 Fritsch, Lageverdnd.erv.ngen der Gebarmutter, 1881. 4 Op. ciL, p. 61. 



PATHOLOGY. 



369 



Pathology. — Flexions may be congenital or accidental. As the 
opposite walls develop, an excess of nutrition may be appropriated by 
one, which grows rapidly, while the other, developing more slowly, 
arrests the erection of the uterus, and, giving it an inflexion, creates 
a concavity on one side and a convexity on the other. If the posterior 
wall develop most decidedly, an anteflexion results ; if, as was the case 
in 19 out of M. Soudry's 71 autopsies of infants, posterior displacement 
exist, and the anterior wall receive the chief amount of nutrition, a 
retroflexion is the consequence. But not only does the excessive 
growth of one wall create an inflexion on the opposite side ; the side 
which. is bent undergoes to a certain extent atrophy, and this increases 
the already growing disproportion. This, in all probability, is the 
source of congenital flexion, a condition always exceedingly difficult 
of cure, but fortunately one which does not create as much corporeal 
congestion and constitutional disturbance as the more remediable form 
which is accidental. 

In the supplement to the second volume of Herbert Spencer's work 
upon Biology appear some remarks upon the influence of prevailing 

Fig. 175. 




Pathological Anteflexion from Shortening of the Sacrouterine Ligaments (Schultse). 

winds upon the growth of trees, which are interesting in this connec- 
tion. ^ The tree, says he, being habitually bent in one direction, its 
nutrition is, on the concave surface, impaired, the ligneous material 
upon the convex portion is deposited in excess, and in consequence the 

24 



370 



DISPLACEMENTS OF THE UTERUS. 



heart of the tree is not central, but considerably nearer to the concave 
than to the convex surface. Upon experimenting upon growing twigs 
by bending them to one or the other side, he found that he could uni- 
formly produce the same result. When the uterus is flexed a similar 
change will be found to occur from a like cause. 

Congenital anteflexion is much more common than congenital retro- 
flexion. Cases of the latter are, however, by no means unknown. 
Boivin and Duges 1 report 2 cases, Dubois 1, Deville 1, and Bell 1 in a 
very young girl. We have several times met with it. 

Virchow was one of the first to attribute the formation of flexions 
to the construction of peritonitic adhesions in front or behind the uterus 
respectively. B. S. Schultze 2 is the most earnest believer in the 
dependence of many cases of anteflexion on a shortening (congenital or 

Fig. 176. 




Retroflexion of the Uterus from Anterior Fixation of the Cervix (Schultze). 

inflammatory) of the sacro-uterine ligaments, and even gives an illustra- 
tion of the production of retroflexion by anterior fixation of the cervix. 
As regards anteflexion, we think he is right in many instances, although 
we believe that he exaggerates the frequency of preceding inflammatory 
contraction of the posterior uterine ligaments, especially in virgins with- 
out any such history. 

Any influence which weakens the tissue constituting the uterine 

1 Cusco. op. cit., p. 34. 2 hoc. cit, 1881. 



PATHOLOGY. 371 

walls creates flexion. If the posterior wall be chiefly affected, the 
body falls backward ; if the anterior, it inclines forward ; if both, the 
direction of inclination is decided by extraneous forces. Rokitansky 
has proved that such weakening is accomplished by endometritis, which 
creates an inward growth of the utricular glands into the submucous 
connective tissue near the os internum, which in consequence undergoes 
atrophy and enfeeblement ; or by cystic degeneration in the cervical 
glands, " which, from their increased size and subsequent pressure, 
cause the submucous stratum to become atrophied, and which, ultimately 
bursting, thereby cause a collapse of tissue in the formerly dense frame- 
work of the uterus, leaving in its place a flaccid, netlike areolar tissue 
incapable of sustaining the organ in its normal position." Both these 
occurrences, says Klob, take place quite frequently. Rokitansky says 
that in the anterior semicircle of the uterine tissue around the os inter- 
num of women who have borne many children a large transverse vein 
is found, which, by its removal of tissue, weakens the wall. 

But there are other influences which may accomplish this result : 
abscess of the uterine tissue ; development of fibroids which disorder 
the blood-vessels ; varicose degeneration of the veins and sponginess of 
tissue engendered by prolonged traction upon the neck ; disturbance of 
nutrition by flexure created suddenly by a blow or fall, or gradually by 
traction from false membranes, subinvolution, or areolar hyperplasia, 
which accomplishes on a large scale the substitution " for the dense 
framework of the uterus of a flaccid, netlike areolar tissue, incapable 
of sustaining the organ," which Rokitansky declares occurs at the os 
internum in cystic degeneration. 

This loss of power in one or both walls of the uterus is frequently, 
though not universally, the cause of flexions of accidental character. 
They are sometimes due to force sufficiently strong to overcome the 
resisting power of the uterine tissue, either suddenly or by slow degrees. 
Once flexed, one wall soon undergoes degeneration, and thus two 
causes for a continuation of the condition are combined. 

The point of greatest weakness is the point at which flexion occurs, 
and this is usually opposite the os internum. In anteflexion it may 
occur below this point, when the neck only is flexed, from prolonged 
and habitual constipation. In both retroflexions and anteflexions we 
have known it to occur at the middle of the body, and escape super- 
ficial examination or induce a belief in the existence of fibrous tumor. 
Klob has noticed this but once, and has failed to find an analogous 
instance. Cusco 1 records one case in his own experience where the 
body was equally divided by a flexion, and quotes Ashwell and Bell 
for others of similar character. 

Formerly it was supposed that the bevelling of the uterine body at 
a more or less acute angle, either backward or forward, must necessarily 
interfere with the influx and egress of blood from the upper portion of 
the organ, and therefore produce at first acute, and in time chronic, 
congestion of that part, with the resultant hyperplasia o\' the stoma 
and catarrh of the mucous lining. Most emphatic in his support o\' 
this view of the subject was, and still is, Hewitt, who says: "It is 

1 Op. <•//., p. 37. 



372 DISPLACEMENTS OF THE UTERUS. 

somewhat surprising that the occurrence of mechanical congestion of 
the body of the uterus, arising from mere change of shape of the organ, 
as above pointed out, should not have attracted the attention of uterine 
pathologists." Klob coincides with these views, and adds that "the 
reflux of blood from the uterine to the hypogastric veins is interrupted 
(by the flexion), and in consequence of the collateral hyperemia fre- 
quently a very considerable dilatation of the plexus pampiniformis takes 
place, because the blood can now only flow through the spermatic vein." 

[I myself, since the appearance of Klob's work on Pathological Anatomy, 
published in 1868, had paid special attention to this subject and made it a 
prominent feature of my lectures. — T. G. T.] 

[During the last ten years, as the result of increased observation and 
experience, a marked change has taken place in my views on the pathology 
of flexion of the uterus and its significance as a factor in the production 
of disease of that organ and its appendages. At the present day anteflexion 
is generally considered to be, in its minor stages, a physiological (even con- 
genital) condition, only productive of evil under accidental complications, 
and retroflexion is usually looked upon as a sequel to or companion of retro- 
version, and of no special consequence in itself. — P. F. M.] 

At the point of flexion the cervical canal may be more or less closed 
by apposition of its walls. From this cause the ingress of fluids may 
be prevented, and sterility may result. 

Complete closure of the uterine canal by a flexion can occur only 
when agglutination of the opposing surfaces has taken place ; therefore, 
retention of blood, serum, mucus, or air in the uterine cavity cannot 
be caused by simple flexion. 

Whether a flexion, even of the highest degree, can prevent the 
egress of fluids from the uterine cavity seems exceedingly doubtful. 
Some recent authorities claim that not even pain is produced by the 
passage of menstrual blood through a flexed uterine canal, and thus 
deny the occurrence of obstructive dysmenorrhoea. We confess that 
we do not consider this question as yet quite settled. While some wri- 
ters will not admit that flexions are either pathological or produce 
any symptoms whatever, our experience recalls numerous instances in 
which painful menstruation, existing together with more or less anteflex- 
ion, was entirely relieved by a dilatation of the uterine canal, and others 
where sterility, for which no other cause than anteflexion could be found, 
was followed by conception after the canal w T as dilated and kept straight 
for some time by a stem pessary. Of course it does not necessarily 
follow that jwst hoc in these cases means propter hoc ; still, the inference 
is natural and by no means impossible. [On this point my views and 
those of Dr. Thomas do not quite agree, he still believing in the posi- 
tive obstructive power of a sharp anteflexion. — P. F. M.] 

Some writers claim that menstrual congestion straightens the ute- 
rus and facilitates the escape of the menstrual blood. Our opinion is 
rather that a flexion which in the intermenstrual period offers no angle 
of obstruction becomes an obstacle to the exit of menstrual blood in 
consequence of the enormous increase in diameter of the mucous mem- 
brane at that time. This view explains why the pain disappears after 



RESULTS AND COMPLICATIONS— ETIOLOGY. 373 

the blood has begun to escape, for then the temporary congestion is 
relieved, the mucosa shrinks, and the obstruction is effaced for the 
time being. 

In congenital flexion the circulation of the uterus is so gradually 
interfered with that marked congestion is not so likely to occur as it is 
when the organ is suddenly bent upon itself, nor is occlusion of the 
cervix ordinarily so complete. 

Results and Complications. — In place of the long list of patholog- 
ical consequences formerly attributed to flexion of the uterus, the 
observations of recent years compel us to substitute two conditions only 
which may without exaggeration be held to depend on the aggravated 
varieties of this deformity — viz. dysmenorrhea and sterility. 

Many gynecologists of the present day deny that flexion produces 
even these two results. But, as we have already stated, our own expe- 
rience leads us to accept them, mainly for the reason that, no other 
apparent cause for the painful menstruation or sterility being present, 
the dilatation and straightening of the organ have in our hands so com- 
monly resulted in a relief or cure of both conditions that we have been 
forced to assume that the symptoms depended on the flexion. We 
admit, however, that dilatation of the uterine canal may overcome a 
neuralgic or spasmodic contraction of the internal os, and thus relieve 
the dysmenorrhea, or that the better drainage of the cavity brought 
about by this same treatment may open the way for conception. Nei- 
ther will we deny that if uterine congestion happens to exist with a 
flexion, the congestion may cause the dysmenorrhea. 

Etiology of Uterine Displacements. — Both in didactic and clinical 
teaching we have for many years grouped the causes of uterine dis- 
placement in the manner about to be described. Enlarged experience 
with the method leads us to regard it with increased favor, and we 
would urge its claims to adoption by teachers and students. By it no 
influence producing displacement escapes classification, and it induces 
him who employs it to arrange the subject systematically in his 
mind. 

The general causes of uterine displacement may thus be tabulated : 
1st. Any influence which increases the weight of the uterus ; 
2d. Any influence which enfeebles the supports of the uterus ; 
3d. Any influence which displaces the uterus by pressure ; 
4th. Any influence which displaces the uterus by traction. 

To state this more fully in other words — 

1st. The uterine supports are equal to sustaining the organ when of 
normal weight ; but when its weight is increased they naturally foil in 
their task. 

2d. Even if the uterus be no heavier than it should be, it may 
become displaced from depreciation of that support to which it is enti- 
tled and which was made to sustain it. 

3d. If both the uterus and its sustaining powers be perfectly nor- 
mal, it is evident that direct or powerful pressure may overcome the 
latter and force the organ from its place. 

4th. It is equally evident that, as by a tenaculum fastened in the 
uterus of the cadaver we may drag it from its position, so may contract- 



374 DISPLACEMENTS OF THE UTERUS. 

ing adhesions following pelvic inflammation or a prolapsed vagina effect 
this in a living body. 

All these facts having been premised, a concise view of the special 
causes of displacements may be thus presented. 

1. Influences increasing iveight of uterus : 

Congestion ; 

Tumors in the walls or cavity ; 

Pregnancy ; 

Excessive growth of any of its component parts ; 

Subinvolution. 

2. Influences iveakening uterine supports : 

Rupture of the perineum and posterior vaginal wall ; 
Weakening of vaginal walls from subinvolution or over-disten- 
sion ; 
Stretching of uterine ligaments ; 
Relaxation of pelvic fascia ; 
Abnormally large pelvis ; 
Any influence impairing sustaining power of abdomen. 

3. Influences pressing the uterus out of place : 

Tight clothing ; 

Heavy clothing supported on the abdomen ; 

Muscular efforts ; 

Abdominal tumors ; 

Pelvic inflammatory exudations ; 

Repletion of the bladder and rectum ; 

4. Influences exerting traction on the uterus : 

Contracting adhesions following pelvic inflammation, either cel- 
lular or intra-peritoneal ; 
Cicatrices in vaginal walls; 
Shortening of uterine ligaments ; 
Natural shortness of vagina and uterine ligaments ; 
Prolapse of vagina, bladder, or rectum. 
The mode of action of each of these causes is so evident as to 
require no special mention at this time, but it will be particularly 
alluded to hereafter. 

No circumstance combines so many of these causes of displacement as 
utero-gestation and parturition. Should involution follow these without 
interruption, no tendency to displacement results. But the process of 
involution is frequently interfered with. Then, as consequences of the 
arrest of retrograde metamorphosis, the uterus remains large and heavy, 
the vagina voluminous and feeble, and the uterine ligaments, which owe 
their strength chiefly to the uterine muscular tissue which they contain, 
lax and weak. As a result of parturition, too, the perineum is often 
enfeebled, which allows of prolapse of the vagina, which produces trac- 
tion upon the uterus. 

These remarks apply to true displacements of the uterus. To flex- 
ions or deformities of the organ itself they do not so sufficiently apply 
as to render uncalled for some special remarks, which we now proceed 
to offer. 

Predisposing Causes of Uterine Flexions. — Any cause which pre- 



CAUSES. 375 

* 

disposes to enfeeblement of uterine tone, to the development of a force 
which overcomes this even when unimpaired, or, still more, one which 
combines the two evil influences, prepares the way for flexure of the 
uterus under the impulse given by a sudden or persistent exciting cause. 
They may be thus enumerated : 

Parturition ; 

Impoverishment of the blood ; 

Extreme youth or age ; 

Laborious occupation ; 

Relaxation of abdominal walls ; 

Influences altering pelvic axes. 
Exciting Causes. — One of the functions of the cervix uteri is to 
support the body, and for the performance of this it is abundantly com- 
petent unless its powers be impaired by one of the following influences : 
Influences iveakening uterine support : 

Endometritis ; 

Pregnancy ; 

Subinvolution ; 

Areolar hyperplasia. 
Influences increasing the weight of the fundus : 

Enlargement of the body from subinvolution or hyperplasia ; 

Pregnancy ; 

Tumors. 
Influences pushing the fundus or cervix forward or backward : 

Abdominal or pelvic tumors ; 

Ascites ; 

Fecal accumulation ; 

Tight clothing ; 

Muscular efforts. 
Influences exerting traction forward or backward: 

False membranes from pelvic peritonitis. 
Of the first class of causes, inflammation affecting the mucous mem- 
brane of the neck and creating areolar hyperplasia in the parenchyma 
is, according to my experience, one of the most frequent. The hyper- 
plasia thus arising results in atrophy of the muscular and submucous 
fibrous structures of the uterus and their replacement by hypertrophied 
areolar tissue, and produces a marked tendency to this deviation by 
thus substituting a lax and feeble for a dense and powerful substance. 
Klob declares that this replacement of strong tissue by that which is 
weaker occurs more especially near the os internum. Yirchow denies 
the agency 'of this condition as a causative influence, as he likewise does 
that of fatty degeneration, observed by Scanzoni, at the point of flex- 
ure. The influence of parturition, abortion, and pregnancy has been 
admitted by all authorities. 

The varieties coming under the head of the second set of causes are 
all universally admitted, as are also those belonging to the third. Fecal 
impaction may possibly produce flexion of the body, and frequently 
causes the cervix to bend sharply forward. The fourth set of causes is 
put beyond question by the fact that in autopsies the uterus is often 
found thus bound in a state of flexion. 



376 DISPLACEMENTS OF THE UTERUS. 

The etiology of cervical flexion is somewhat different from that of 
corporeal. It is, we feel satisfied, generally induced by pressure 
directly exerted upon the uterus by tight clothing, which forces it 
against the concave surface of the vagina. This surface gives the 
impinging part a slant forward and keeps it thus bent. Habitual con- 
stipation increases this vicious curve, and the two causes combined often 
result in "this unmanageable form of the affection. This explains the 
fact, which all must have noticed, that in pure corporeal flexion the 
uterus is often high up in the pelvis, while in that of cervical form it is 
almost invariably low down. It likewise explains what our observa- 
tion leads us to regard as a" fact, that in nulliparous women the cervical 
and cervico-corporeal varieties preponderate in frequency over the cor- 
poreal form, which is generally met with in multiparous women. 

There is still another pathological element which enters into the eti- 
ology of cervical flexions, and explains the phenomena with regard to 
them which we have just mentioned. The uterus being forced down- 
ward by influences exerting themselves upon the abdomen, if the utero- 
vesical ligaments be lax and yielding corporeal flexion will occur, the 
cervix retreating under pressure. If, however, these ligaments keep the 
cervix in close contact with the bladder, cervico-corporeal or pure cer- 
vical flexion will be developed. Parturition does more to stretch these 
ligaments than anything else, and thus cervical flexion is not so gen- 
erally met with in women who have gone through that process as in 
those who have not. Corporeal flexion is the variety seen after parturi- 
tion ; the cervical and cervico-corporeal forms those which we see in 
nulliparous women. Not only is this fact interesting in reference to 
pathology ; it has an important bearing upon the treatment of cervi- 
cal flexions. He who would treat these cases successfully must sys- 
tematically stretch the ligaments which keep the cervix in an anterior 
position, and by this means strive to change the form of displacement 
to that of corporeal flexion or of anteversion. 

Retroflexion is most frequently the result of some influence which 
weakens the tone of the uterine walls, but even when this is normal 
any force directly applied may displace it and produce a flexure, whether 
such force is developed suddenly or gradually. 

We have now pursued the study of flexions, as a whole, as far as it 
is profitable to do so, and from this point they shall be considered under 
separate heads. 

The uterus may be flexed upon itself anteriorly, posteriorly, or later- 
ally, giving rise to the disorders known as — 
Anteflexion ; 
Retroflexion ; 
Latero-flexion. 

The fundus in falling forward or backward does not always pre- 
serve the median line, but commonly falls obliquely to the right or 
left. This obliquity is frequently created, even where the median line 
was originally preserved, by the use of a pessary, and constitutes so 
prominent a difficulty in these cases that we employ a special instru- 
ment for its treatment. 

Thus we may find a uterus flexed forward and laterally, backward 



ASCENT OF THE UTERUS. 377 

and laterally, or the whole organ may be tilted backward, while its 
body is anteflexed. 

These varieties are known as — 

Ante-latero-flexion ; 

Retro-latero-flexion ; 

Retroposition and anteflexion ; 
with minor varieties of the same displacements. 

This is all that need be said upon the subject of uterine displace- 
ments in general. We shall now proceed to complete the outline here 
sketched and go into the details connected with each variety of the 
affection. 



CHAPTER XXVIII. 

ASCENT AND DESCENT OF THE UTERUS. 

Ascent of the Uterus. 

In its normal condition the uterus descends into the pelvic cavity so 
that its neck assumes a position about two inches from the vulva. If its 
weight be augmented, it comes much lower than this, and continues to do 
so as its volume increases until its development becomes so great that 
it cannot be accommodated by the pelvis. Then it escapes from the 
cavity by ascending to a more capacious space above the superior strait. 
This change occurs in every normal pregnancy. During the first three 
months the uterus falls in the pelvis, being in a state of prolapse. As 
the fourth month approaches its volume becomes so great that it can no 
longer be retained in the pelvic cavity, and then it escapes above the 
superior strait, where sufficient space is afforded for it to undergo full 
development. This is not only so in pregnancy ; the uterus is similarly 
affected by morbid growths. When, under these circumstances, it leaves 
the pelvis, the fact is expressed by the term ascent. 

Accordingly as the pelvic tumor develops in one or the other part 
of the pelvic cavity the uterus is pushed upward in the opposite direc- 
tion. Thus ovarian tumors, which are mostly situated behind ' the 
uterus, cause that organ to ascend anteriorly so long as they are still 
contained in the pelvic cavity ; and the same applies to fibroid growths 
springing from the posterior wall of the uterus, or to malignant masses 
developing in the retroperitoneal cellular tissue. Besides the ante-, 
retro-, or lateral elevation of the uterus, there is often more or less 
twisting or torsion of the organ. 

Ascent of the uterus is never an original disease, but the result 
of some important change connected with that organ, and requires 
merely a mention. It may occur whenever a tumor is developed in 
connection with the vagina, rectum, or recto-vaginal cul-de-sac. when 
there exists a growth in the walls or cavity of the uterus which ren- 
ders it too large for accommodation in the pelvis, or when an abdominal 
tumor draws up the uterus. It never requires treatment, and is of 



378 ASCENT AND DESCENT OF THE UTERUS. 

importance only as exciting suspicion of pregnancy or as an evidence 
of morbid growth in some way connected with the organs of generation. 

Descent or Prolapsus of the Uterus. 

Definition , Synonyms, and Frequency. — The name of this disorder 
defines its character with sufficient clearness. It is of frequent occur- 
rence, and under the name of falling of the womb is well known to 
women, and constitutes for them an object of especial dread. As 
almost all women, after the period of fruitfulness has passed, have an 
intuitive fear of cancer of the uterus, so do a large number before that 
time manifest an apprehension of prolapsus. In the one case the anx- 
iety is for life, in the other for usefulness and comfort. 

Unfortunately for the student of this subject, its nomenclature has 
been rendered somewhat obscure. By some all cases of prolapsus in 
which the uterus does not escape from the vagina are termed incomplete, 
while those in which it does are styled complete. By others complete 
protrusion is denominated procidentia ; and by others still a very slight 
descent without alteration of direction of axis has been designated by 
the very old name of " squatting uterus." We have striven to simplify 
the matter by applying the name prolapsus to all, and marking the 
degrees of descent by the terms "first," "second," and "third." 

Anatomy. — Those uterine supports which are especially active in 
preventing uterine descent are the surrounding areolar tissue, which 
binds it to the bladder, the rectum, and the pelvic walls ; the utero- 
vesical and utero-sacral ligaments ; and the retentive power of the 
abdomen. About the sustaining influence of the vagina there is much 
difference of opinion; our opinion formerly was that the promontory 
formed by the vagina in front of the cervix effected something in the 
way of support, but observation has led us to modify very much the 
belief which we once had in the general sustaining influence of the 
canal. Loss of tone in it, resulting in prolapsus vaginae, is commonly 
attended by a similar prolapse in the uterus, but it does not follow that 
the uterus falls from want of support ; it is more probably dragged down 
by the heavy vagina. This view may be sustained by so many strong 
arguments that it need not invoke weak ones. A good deal of stress 
has been laid upon an experiment for which Aran credits Stoltz, that 
of cutting the vagina away without noting any descent of the uterus. 
A little reflection must show that this proves almost nothing. It merely 
demonstrates the fact that without the vagina other supports are suf- 
ficient to sustain the uterus. No one has ever maintained that the 
vagina was the only support which keeps the uterus up, nor that others 
were insufficient without it. 

A great deal of support is unquestionably derived from the connec- 
tive areolar tissue, which so closely unites the uterus with the rectum, 
bladder, and pelvic walls as to involve displacement of these viscera in 
its descent. Dr. Savage, dragging the uterus of a cadaver forcibly 
downward by means of a vulsellum attached to the neck, found that 
after cutting its important ligaments and overcoming by force the action 
of the vagina it still would not advance. " The obstruction was found 



CAUSES OF PROLAPSUS UTERI. 



379 



to be due to the subperitoneal pelvic cellular tissue, particularly where 
it surrounds and accompanies the uterine blood-vessels." 

The most important factors in the prevention of prolapse are the 
utero-sacral ligaments, which Aran considered the only real ligaments 
of the uterus. Arising from the point of junction of neck and body, 
they usually embrace the rectum in their bifurcation posteriorly, and, 
diverging on each side of it, terminate in the subperitoneal cellular tis- 
sue as high up as the second lumbar vertebra. They are exceptionally 
inserted into the rectum. It was the recognition of this anatomical 
arrangement of these important ligaments which led Huguier to sug- 
gest that they be called utero-lumbar instead of utero-sacral. They 
consist of the following elements : peritoneum, pelvic connective tissue, 
uterine cortex, and vaginal muscular fibre. Their influence, as likewise 
to a much less degree that of two similar bands connecting; the cer- 
vix in front with the bladder, cannot be doubted. 

These are probably all the factors which unite in the prevention of 
prolapsus in the first and second degrees. When they are entirely 
overcome and the descent has become complete, the round and broad or 
lateral ligaments come into action, but not until that has occurred. 

Varieties. — This displacement may occur very suddenly and unex- 
pectedly, or gradually and by successive steps. As the symptoms of 
the two varieties differ only in the rapidity 
and severity of their development, and the 
second is much the more frequent, we shall 
direct our remarks chiefly to it, and describe 
the first in a few T words in an appropriate 
place. 

Prolapsus may exist either in the first, 
second, or third degree, the direction of the 
uterine axis in each of which is exhibited in 
Fig. 177. 

In the first the uterine axis is bent for- 
ward, the organ being somewhat ante verted 
and sunk in the pelvis. In the second the 
body has gone toward the sacrum, the cer- 
vix having come down to the ostium vaginae. 
In the third the last barrier has been over- 
come, and either a part or the whole of the 
uterus hangs between the thighs. 

Causes. — The causes which predispose to 
this accident are — 

Child-bearing ; 
Laborious occupations ; 
Advanced age ; 
Habitual constipation. 

We know of no way in which we can give so concise a summary of 
the exciting causes of prolapsus as by a reference to the classification ro 
which we have already referred under general considerations upon dis- 
placements ; for the exciting causes will be found to belong in every 
case to one of four classes : those increasing uterine weight : those 





Fig. Yi 


7. 






^3iq 


3 

A 




j, ■*<< 


% 


/ 

/ 
/ 


--"7 if J 


/• 






w s 




> 


r/s 





Diagram representing 
Axis in the Three 
Prolapsus. 



the Uterine 
Degrees of 



380 



ASCENT AND DESCENT OF THE UTERUS. 




enfeebling uterine supports ; those forcing the uterus down by power 
applied above: and those drawing it down by traction from below. 

a. Examples of causes con- 
rG ' ' ' nected with increased uterine 

weight : 

Tumors, submucous, sub- 
serous, or mural ; 

Pregnancy (rare, but 
sometimes met with) ; 

Hypertrophy or hyper- 
plasia ; 

Retained fluid (rare). 

b. Examples of causes con- 
nected with enfeeblement of 
uterine supports: 

Abnormally capacious 
pelvis ; 

Destruction of power of 
the perineum ; 

Loss of tone of vaginal 
walls ; 

Loss of tone of uterine 
ligaments ; 

Absorption of fat from 
pelvic areolar tissue ; 

Atony of abdominal mus- 
cles ; 

Diminution of power of 
respiratory muscles. 

c. Examples of influences forcing the uterus downward: 

Violent coughing ; tumors in abdomen ; 
Ascites ; violent muscular eflbrts ; 
Tight and heavy clothing ; 
Straining at stool. 

d. Examples of influences dragging the uterus down : 

Congenital or acquired shortness of the vagina ; 
Prolapse of vagina, bladder, or rectum. 
We have already stated that these evil influences are most completely 
combined in the condition existing after parturition, when the uterus is 
heavier than normal, the recentlv-distended vagina relaxed and feeble, 
the uterine ligaments very much stretched, and the sphincteric muscles 
of the vagina weakened. When, as so often happens, rupture of the 
perineum and of the cervix uteri occurs, and is followed by subinvolu- 
tion of vagina, uterus, and uterine ligaments, we have in perfection all 
the conditions which give rise to this displacement. Of all the causes 
of prolapsus this combination is the most frequent, and hence the diffi- 
culties attending cure. It is for this reason that prolapse is found to 
be rare in women who have never borne children, less rare in those who 
have borne one only, and appears to increase in frequency in proportion 
to the frequency of the parturient process. Scanzoni reports that in 



Parous Vulva. 

Showing gaping of vaginal orifice ami consequent 
inclination to descent of vaginal walls. (Compare 
with cuts of virgin and nulliparous vulva? on pp. 
123,124.) 



PATHOLOGY OF PROLAPSUS UTERI. 381 

114 cases of prolapsus, 99 occurred in women who had borne children. 
Winckel 1 says that of 349 women with prolapsus, 22.5 per cent, were 
between twenty and thirty years of age, 22 per cent, from thirty to 
forty, and 25.2 per cent, from forty to fifty. Of these 26 per cent, had 
borne one child, 52 per cent, one to five children, and 22 per cent, from 
five to ten. Even the most complete prolapse, however, will some- 
times be met with in young and unmarried women. Within the past 
few years we have met with 7 such cases, 3 in virgins of seventeen, 
nineteen, and twenty-four, 3 in old maids between fifty and sixty, and 
1 in a healthy laboring woman at the menopause. 

Next in order of frequency will be found a, condition which occurs 
in old women — a loss of vaginal power from atrophy of the vagina and 
absorption of the padding of fat which normally occupies parts of the 
pelvis and helps to aid that canal in sustaining the uterus. This condi- 
tion has been specially mentioned by some of the German pathologists, 
and attention has been called to its importance by Dr. Barnes of Lon- 
don. Here, although the uterus is atrophied, it descends in spite of 
its lightness, partly from loss of support from the vaginal promontory 
and partly from traction exerted upon it by the prolapsing vaginal walls. 

An important position as a pathological factor is assumed by loss of 
the retentive power of the abdomen. Want of exercise except in walking 
induces in women very commonly an atonic condition of the thoracic and 
abdominal muscles, and the respiratory act therefore becomes inefficient 
and the piston function of the diaphragm feeble and imperfect. As a 
consequence of this failure the uterus rises in the pelvis at each expira- 
tion less perfectly than it ought ; its circulation, lacking the stimulus 
of the abdominal rise and fall, becomes sluggish ; gradually it settles 
lower and lower in the pelvis, and becomes a readier prey to the action 
of other malign influences. 

Relaxation of the abdominal walls probably also favors displacement 
by effecting an alteration of the direction of pressure transmitted to the 
uterus, bladder, and superior vaginal wall, and by permitting the free 
entrance of intestines into the anterior peritoneal prolongation or ante- 
rior uterine excavation. 

Increased uterine weight and pressure from above are so plainly 
active in creating prolapsus that no one will doubt their causative influ- 
ence. By its instrumentality we see complete prolapsus occur, with 
ovarian tumors, ascites, etc. 

Pathology. — There formerly was no variety of displacement about 
the pathology and mechanism of which gynecologists were more at 
variance than this, and yet none to which a greater amount of honest 
scientific labor has been applied for the elucidation of these very points. 
As examples we may cite the experimental researches of Aran, 2 Legen- 
dre, 3 Huguier, 4 Savage, 5 and Taylor, 6 to which the seeker after more 
elaborate data is referred. 

1 Lqc. cit., 1889, p. 261. 

2 "Etudes anatomiques et Anatomo-pathologiques sur la Statique do lTtorus." 
Paris, 1858, Archie. Gen. de Med, 3 De la Chute de /' Uterus, Paris. 1860. 

* Les Allongements hypertrophiques du Col de /' Uterus, Paris, L859, 

5 Female Pelvic Organs, London, 2d ed., 1870. 

6 On Amputation of the Cervix Uteri, etc.. Now York, 1869. 



382 ASCENT AND DESCENT OF THE UTERUS. 

Our limited space will not permit us to go fully into the views of 
these investigators, and we shall confine ourselves chiefly to a rather 
dogmatic statement of our own opinions, at the same time acknowledg- 
ing that they are, in great extent, founded upon the investigations 
alluded to. 

At the present day we may fairly say that the manner in which pro- 
lapsus of the uterus is accomplished is well understood, and no longer 
a matter of doubt or discussion. In order to explain to the student, 
however, the train of investigation and reasoning by which this result 
has been achieved, we shall retain the remarks on this subject found in 
our last edition. 

It matters not whether the original cause of the displacement be 
increase of uterine weight, depreciation of sustaining power, or direct 
force exerted upon the organ from above or below ; an invariable result 
of its existence is diminution of the power of the uterine supports. 
The ligaments are stretched, the vagina distended and doubled upon 
itself or everted, and the contractile power of the sphincteric muscles 
impaired. The displaced organ is generally affected by congestion and 
inflammation of the mucous lining, its cavity is much enlarged, and 
solutions of continuity occur upon the cervix. The vaginal rugae are 
effaced, and the lining of the canal, exposed to atmospheric influences 
and friction, looks like the cicatrized surface of scalded skin rather 
than mucous membrane. 

" The tension of the aponeurotic fibres of the broad ligaments," 
says Legendre, " during uterine prolapse results in compression of the 
hypogastric veins, as compression of the veins of the neck occurs from 
tension of the cervical fascia when the head is forcibly thrown back- 
ward. In this way congestion of the uterus and other pelvic organs is 
kept up." Prolapsus, from its influence in thus producing hyperemia, 
is usually attended by hyperplasia of the areolar tissue of the uterus. 
This organ undergoes an absolute increase in size, and the tissue of the 
cervix is especially altered. Simultaneously with hyperplasia there are 
varicose degeneration of the blood-vessels of the cervix and absorption 
of its proper tissue. This increases the natural ductility of the part, 
and upon any traction being applied it stretches so as to produce the 
phenomena of variation in the length of the uterus mentioned under the 
head of Physical Signs. The walls of the vagina are found much thick- 
ened by proliferation of epithelium and hypertrophy of the submucous 
layers of areolar tissue. Thus it becomes not only more capacious, but 
heavier and more voluminous, than normal, and even if its increase in 
volume and weight is a consequence of uterine displacement, it drags 
upon the uterus and increases its tendency to descend. 

The uterus may descend from its normal place in the pelvis under any 
one of the four influences which have been mentioned. It must not, 
however, be supposed that one only is usually active. On the con- 
trary, two, three, and even four, are often combined in furthering the 
result. For thoroughness of study they are examined apart, that course 
being also chosen from the fact that even if several causes are combined, 
one is usually especially prominent as a factor. 



PATHOLOGY OF PROLAPSUS UTERI. 383 

If a careful clinical study be made of this interesting subject the 
uterus will be found to descend in one of these ways : 

1st. A woman who had previously been in good health begins to 
complain of dragging about the loins, backache, and sense of fatigue 
about the pelvis. An examination is made, and the uterus is found 
resting upon the floor of the pelvis, its axis little altered. There is no 
rupture of perineum, no redundancy of vagina, and the habits of life 
of the patient preclude the possibility of muscular efforts or tight cloth- 
ing being agents in the condition. A careful examination of the 
displaced uterus shows it to be large and heavy from subinvolution, 
or discovers a fibrous tumor in its structure. The natural supports 
have been perfect, but they have been overtaxed and have yielded. 
Increased uterine weight is the prime mover in the disorder. 

But keep this case under observation. The descent already effected 
has drawn down the bladder, caused pressure upon the rectum, estab- 
lished a hyperemia in the tissues of the vagina, and begun already to 
rob the uterine ligaments of their power by stretching them. Pres- 
sure on the rectum and dragging upon the bladder create irritation, the 
patient " bears down " in evacuating these viscera, and a new influence 
is developed — force from above. Very soon congestion of the vagina 
results in excessive areolar growth, this canal falls into its own dis- 
tended channel, and another evil influence is the result — traction upon 
the uterus from below. The uterus has now descended, so that its os 
projects between the labia majora; if its ligaments were stretched 
before, how much more so must they be now ! 

2d. A uterus is found in the first degree of prolapsus. It is a 
healthy uterus, normal in size, weight, and consistency. Its supports 
appear perfect, and no influence exerts traction upon it from below. 
Everything is normal but one — the uterus has descended. Examina- 
tion proves that this woman has labored hard, lifting heavy weights, 
and placing herself in a constrained attitude to do so ; or she has for 
weeks suffered from a spasmodic, violent cough or from obstinate con- 
stipation, which has caused tenesmus. The cause of the prolapse is 
evidently force applied to the uterus from above. But this remains 
the sole cause for a short time only. Very soon increased weight of 
the uterus from congestion, enfeeblement of uterine supports from pro- 
longed tension, and traction by falling of the hypertrophied vagina and 
prolapsed bladder complete the vicious circle. 

3d. An examination of the uterus in a case exactly similar as to 
symptoms demonstrates no increase of uterine weight, no force applied 
from above. The woman is found to have a justo-major pelvis, which 
has always resulted in precipitate labors ; or she is past sixty and a 
senile atrophy is developing; or -the perineum is ruptured, and the 
anterior and posterior vaginal walls are protruding in egg-like pouches 
at the vulva, not sufficiently to drag upon the uterus," but enough to 
shorten the vagina by allowing its distal end to protrude : and thus the 
vaginal promontory is removed. The mischievous factor is loss of 
uterine support. The uterus is normal in weight and exposed to no 
evil influences from pressure or traction, but its feeble supports even 
then are unfit for their functions, and the uterus falls. It descends to 



384 ASCENT AND DESCENT OF THE UTERUS. 

the second degree, and, dragging upon the broad ligaments, their apo- 
neurotic expansions compress the hypogastric veins, great congestion 
results, and at once a new influence develops — increased uterine weight. 
Now rectal and vesical tenesmus and pressure by the displaced abdomi- 
nal viscera add another untoward element — force applied from above. 
And as the descending uterus everts still further the congested, volu- 
minous, and heavy vagina, it drags the offending organ still more 
rapidly down. 

4th. The reader, wearied by repetition, may crave a respite here, 
but he asks it just where it cannot be granted, for we come to the 
consideration of the most frequent and consequently most important 
of all the influences resulting in prolapsus uteri. Prolapse of the ute- 
rus is sometimes a primary affection, but in the great majority of cases 
it is secondary, produced by prolapse of the vagina, which literally 
drags it from its position. There are two methods in which this occurs : 
1st. The perineum is ruptured, and by this the vaginal walls lose the 
buttress against which they rest, and the power of the pubo-coccygeus 
muscle is diminished. 2d. A vagina developed by utero-gestation does 
not undergo involution, but remains a large, voluminous, and heavy 
bag, the redundant walls of which overcome the resistance of the peri- 
neal body and prolapse, dragging the uterus down, either before or 
simultaneously with their escape from the vulva. 

Dr. Duncan, in an essay read before the Edinburgh Obstetrical 
Society 1 in 1871, maintained that the perineum had nothing to do 
with the support of the uterus, and that therefore laceration of this 
part is not a cause of prolapsus. We do not believe that the perineum 
supports the uterus directly, nor that upon the cadaver its section would 
result in prolapsus ; but Ave believe that destruction of the perineal 
body, which acts as a support to the vagina, results in loss of support 
to both its posterior and anterior walls. These prolapse, their tissue 
becomes hypertrophied, and they drag down the bladder and then the 
uterus. Look at Fig. 57, and see how much support vagina and blad- 
der obtain from the perineal body, and the results of its rupture may 
be better appreciated. So long as the vagina is normal in volume and 
weight, and remains within the pelvis with its walls in apposition, it 
constitutes, by its ante-cervical projection, we think, a uterine support. 
So soon as it falls from the pelvic cavity, becomes hypertrophied, and 
has its walls separated, it not only loses this power, but degenerates into 
a uterine tractor. 

The same authority points to the fact that many cases of complete 
perineal laceration do not produce prolapsus uteri. This is true. Such 
laceration is usually the result of parturition, and is, we are satisfied, 
often a cause of subinvolution of the vagina. If this condition has 
resulted, the laceration is very generally followed by prolapsus vaginae, 
and thus by descent of the uterus. If vaginal involution have not been 
interfered with, it is usually not so. 

Aran points out the fact that removal of the vagina from the cada- 
ver does not produce uterine prolapse, and Dr. Duncan declares, " I 
have no doubt that if, by way of experiment, the perineum was cut 

1 Transactions, vol. ii. p. 269. 



PATHOLOGY OF PROLAPSUS UTERI. 385 

through in a healthy woman, no tendency to prolapsus would be thereby 
produced." We freely accept both experiment and proposition, but we 
cannot agree in the deductions based upon them. When the uterine 
ligaments are strong, the uterus does not readily leave its position. 
Sometimes traction steadily exerted upon the cervix fails to draw down 
the body, but stretches the neck, so that the uterus measures by the 
sound between six and seven inches. In many cases, before prolapse 
occurs, the uterus is affected by areolar hyperplasia or the local atrophic 
state engendered by flexion, which last Dr. Hewitt regards as a frequent 
source of it, and when thus weakened it readily yields to traction. 
When the tractile force is checked by reposition of the uterus the neck 
instantly contracts, and the length of the whole organ greatly dimin- 
ishes. 

May this fact not explain the experience of Huguier, who found 
only 2 cases of true prolapse in 60 reported cases, and of Routh, who 
in a large experience met with only 3 ? It seems to us highly probable 
that these investigators, making their measurements while the uterus 
was prolapsed to the third degree, concluded that hypertrophic elonga- 
tion of the supravaginal portion existed, when in reality this peculiarly 
elastic tissue, which was the consequence and not the cause of the 
descent, was the true pathological condition. Certainly some such 
explanation must account for the remarkable discrepancy which exists 
between the results of these two eminent gynecologists and the great 
majority, whose experience is opposed to theirs. 

In these cases the force of traction appears to expend itself upon 
the most powerful uterine ligaments, those inserted at the axis of rota- 
tion, the cervico-corporeal junction. They yield, and the cervix 
advances toward the vulva, but the uterus, supported though it is by 
factors of less power, resists steady traction, and remains in place. 
Legendre attached to the cervix uteri of a cadaver a weight of fifteen 
kilogrammes, which was gradually increased to fifty during the period 
of an hour, then diminished to thirty, and kept up traction by that for 
two hours. At the commencement the uterine canal measured by the 
sound five centimetres, and at its conclusion nine, the lengthening being 
chiefly in the cervix. In other experiments a less weight kept in 
action for several days caused complete prolapse with elongation of the 
cervix uteri. 

Since the appearance of Huguier's essay upon supra- and infra- 
vaginal elongation of the cervix as conditions commonly mistaken for 
prolapsus, writers have commonly considered hypertrophic elongation 
of the cervix below the vaginal junction under this head. We shall 
not do so, because the propriety of such a course seems to us to be sus- 
tained neither by clinical observation nor pathological investigation. 
and because true cervical hypertrophy will be elsewhere treated of. 

That there is a form of hypertrophic elongation of the cervix uteri 
which occurs below the cervico- vaginal junction, and appears upon very 
superficial examination to resemble prolapsus, or even produces that 
conditioned by traction, Ave of course admit. But it appears to us 
erroneous to regard supravaginal elongation — which is marked by an 
attenuation of the tissues of the neck and "a spongy softness," accord- 



386 ASCENT AND DESCENT OF THE UTERUS. 

ing to Klob attributable to a " varicose condition of the blood-vessels 
and absorption of the cervical tissues" — as true hypertrophy. 

It is highly probable that this condition, the result of traction, may 
occur during pregnancy and exist as a source of great annoyance after 
it. This elongation of the uterine neck is so commonly found in pro- 
lapsus uteri, if the disease has existed for some time, as to be demon- 
strable with as much certainty as the almost invariable simultaneous 
backward displacement of the body of the organ. With the uterus 
prolapsed and retroverted the sound will enter from five to seven inches. 
After replacement of the organ its cavity measures only three to four 
inches. Emmet has compared this peculiar tractility to the drawing out 
and reposition of a column of putty. 

Course, Duration, and Termination. — Prolapsus uteri is unlimited 
in its duration, and, unless relieved by art, will continue indefinitely. 
It impairs the patient's comfort and capacity for exertion, but rarely 
has a fatal termination, unless by exciting peritoneal inflammation or 
pelvic cellulitis, as we have seen it do in several cases. Even in the 
chronic form of the disease death has in very rare cases occurred from 
uraemia, the result of interference with the ureters. The trigone of the 
bladder becoming displaced to such an extent that the orifices of the ure- 
ters are pressed firmly against the symphysis pubis by the mass behind 
it, they become obstructed and distended, and in time hydronephrosis 
may result. Virchow 1 and Kiwisch 2 . both announce this fact. An 
interesting instance of death thus produced may be found in the 
twelfth volume of the Transactions of the London Obstetrical Society, 
reported by Dr. Phillips. [In a case of incarcerated uterus occurring 
in my own experience, and which will receive further mention elsewhere 
in this article, I was compelled to resort to a degree of force in return- 
ing the displaced organ which at the time of application I regarded as 
attended by extreme danger. Had my efforts not succeeded, death 
would, I feel sure, have resulted, for the uterus and surrounding parts 
appeared to be about passing into a state of gangrene. This case 
before I saw it had resisted all the efforts which were applied by three 
competent physicians. After forcible replacement the entire lining 
membrane of the vagina sloughed, and the patient narrowly escaped 
death from peritonitis, which was excited and ran a violent course. 
Forcible taxis was resorted to, with a conviction on the part of the 
attending physicians and myself that the issue involved either restitu- 
tion of the uterus or death.— T. G. T.] 

Symptoms. — The symptoms of prolapsus are dependent upon two 
results growing out of the displacement : the mechanical interference 
of. the womb with surrounding parts, and alteration induced in its cir- 
culation and tissue by reason of its abnormal position. The uterus may 
remain even in the third degree of descent without any marked symp- 
toms, but generally congestion, areolar hyperplasia, and granular 
degeneration occur, which render it sensitive and intolerant of pressure 
or friction. At the same time, by dragging up the bladder, rectum, 
and all the pelvic areolar tissue and fasciae, and by protruding between 
the labia, it produces discomfort and often impedes locomotion to a 

1 Trans. Obstet. Soc. of Berlin, 1847. 2 Clinical Lectures- 



PHYSICAL SIGNS OF PROLAPSUS. 387 

great extent. The most prominent of the symptoms thus created are 
the following : 

Sensation of dragging and weight in the pelvis ; 

Rectal and vesical irritation ; 

Pain in hack and loins ; 

Great fatigue from walking ; 

Inability to lift weights ; 

Leucorrhoea and other signs of congestion. 
It is a very singular and striking fact that in prolapsus, even of 
the third degree, there is very commonly no menstrual disorder, and 
equally remarkable that sterility does not ordinarily exist. These 
immunities are probably dependent upon the facts that the uterine 
catarrh w T hich usually exists is rather the result of a passive congestion 
of the endometrium than of true inflammation, and that the axis of the 
organ, although altered in direction, is not so bent upon itself that an 
obstruction in it is created. 

Physical Signs. — All the symptoms detailed will only excite suspi- 
cion and prompt an examination which will fully elucidate the case. 
Should the aifection exist only in the first degree, the finger passed 
up the vagina will meet with the os low down in the pelvis and pressing 
upon its floor. As it is slid upward in front of the cervix and along 
the base of the bladder the resisting anterior wall of the uterus will be 
clearly distinguished, and it may be found that anteversion or ante- 
flexion exists, complicating prolapsus. 

If the second degree have been reached, the os will be found at the 
ostium vaginae, prevented from escaping only by the resistance of the 
sphincteric muscles, and the body, instead of lying forward, will be to 
some extent retroverted. To determine the degree of prolapsus, more 
especially in this stage, the patient should be examined standing. 

Sight and touch will combine in making a diagnosis in the third 
degree of prolapse rapid and easy, but even here we have known very 
grievous mistakes committed. The apparent ease of the diagnosis 
sometimes causes error by inducing neglect of that caution and watch- 
fulness which in the simplest cases of disease constitute the only safe- 
guard of the physician. 

The curious elongation and retraction of the uterus so commonly 
found in prolapsus of advanced degree and long standing has already 
been referred to under Pathology. 

Differentiation. — In any of its varieties prolapsus uteri may be con- 
founded with fibrous polypus, inversion of the uterus, and hypertrophic 
elongation of the neck, from all of which, however, it is readily distin- 
guished if the practitioner be aAvake to the possibility of error.' From 
the first it is known by the presence of the os and cervix and the 
general shape of the mass ; from the second by the presence of the os 
and cervix and absence of the signs of inversion. The third will 
readily be recognized by the groat length of the cervix, the impossi- 
bility of replacing the supposed prolapsed organ, and the great depth 
of the uterus discovered by the uterine probe after it has been restored 
to the pelvis. 

Prognosis. — In most cases a great deal of relief can be effected bv 



388 ASCENT AND DESCENT OF THE UTERUS. 

medical and minor surgical means. In a few, in which the displacement 
is secondary to the existence of a large abdominal or perhaps uterine 
tumor, nothing can be done either for relief or cure. In many in which 
descent of the uterus is secondary, due to traction upon it by the pro- 
lapsed vagina, bladder, and rectum, cure can be effected, even where the 
third degree has been reached, by surgical procedures appropriate to the 
cure of the primary displacements which produce traction upon the 
uterus. 

In cases existing only in the first and even the second degree cure 
may, in favorable cases, be accomplished by mere removal of the causes 
which are gradually depressing the uterus. 

Complications. — Prolapsus of the uterus in its first and second 
degrees, and still more frequently in its third, produces the following 
complications : 

Hypertrophic elongation of the cervix ; 
Ulceration of cervix and vagina ; 
E version of lips of cervix ; 
Cystocele ; 
Rectocele. 
The general hyperemia of the uterus, the endometritis, the subin- 
volution and consequent hyperplasia, which were formerly attributed 
to the prolapsus, are now more correctly understood as preceding it, 
and as to a certain extent its causes. 

Replace the uterus and keep it in its normal position for a sufficient 
length of time, and Nature herself will, to a great degree, cure these 
pathological conditions. This statement by no means invalidates the 
production of oedema of the prolapsed uterus and vagina by constriction 
at the vulvar orifice, nor the hypertrophic elongation of the cervix 
already referred to. Nor do we mean to deny that erosion, eversion, 
and ulceration of the lips of the external os take place in the major 
degrees of prolapsus in consequence of the traction of the vaginal walls 
and friction against the exposed cervix. Of course the bladder is dis- 
located with the anterior vaginal wall, so that in many cases a sound 
or catheter passed into the urethra glides downward and backward. 
This complication is important, for not only do traction and dislocation 
tend to the production of cystitis ; it is further induced by reflex irri- 
tation and by decomposition of urine occurring from retention, after 
urination, in the pocket formed by the inverted wall of the bladder. 
By a similar process prolapse of the anterior wall of the rectum occurs 
and results in fecal impaction at this point. 

Sudden or Acute Prolapsus may come on from any great effort, a 
fall, or violent contraction of the abdominal muscles, acting upon a 
uterus which is enlarged by hyperplasia, subinvolution, pregnancy, or 
tumors. It may even occur to a uterus normal in size and consistency. 
In an instant the patient feels that something has given way within 
her, becomes prostrate and much alarmed, and suffers pain of an expul- 
sive character, as if desirous of forcing something from the pelvis. We 
have twice seen it occur within a fortnight after delivery from sudden 
and violent muscular effort, and three times in virgins in consequence of 
the sudden lifting of a heavy weight. One was the case of a girl of 



TREATMENT OF PROLAPSUS. 389 

nineteen years in whom the cervix was driven out of the vulva, the 
body being arrested by the sphincter vaginae and perineal septum. 
When first seen, a year after the accident, she was suffering intensely 
from the displacement, but from false modesty had never told of it. Dis- 
tinct traces of the hymen were visible, which, there was every reason, 
both physical and moral, to believe, had not been ruptured by sexual 
congress. In a second case, a girl of twenty-three, the prolapsed uterus 
and vagina had become so oedematous that it required twenty-four 
hours of compression by the elastic bandage before it could be replaced. 
Some months later the ruptured perineum was repaired by the flap- 
splitting operation. 

In such cases as these it appears to us highly probable that the utero- 
sacral ligaments are ruptured. This supposition, the difficulty of prov- 
ing which by necropsy is apparent, may have attracted attention, but 
the only allusion to it which we have met with is the following from 
Courty, who, in speaking of the utero-sacral ligaments, says, " If they 
are stretched or broken, the entire organ falls." 

In acute prolapsus, should reduction not be effected at once, violent 
pain will be felt over the sacrum and groins, and the degree of traction 
exerted upon the pelvic peritoneum may result in dangerous inflam- 
mation. Besides, oedema of the prolapsed uterus and vagina may 
occur, due to interference of circulation. 

Treatment. — The first indication as to treatment is to return the 
displaced organ to its normal position ; the second, to keep it there. 

Methods of Replacing the Uterus. — In general, no difficulty will 
attend the performance of the first indication, but in some cases careful 
and intelligent taxis will be necessary. The best method for applying 
this is the following : The patient, after thorough evacuation of the 
bladder and rectum, if this be possible, should be placed in the genu- 
pectoral position, in order to cause gravitation of the pelvic and abdom- 
inal viscera toward the diaphragm. She should not kneel upon a soft 
or yielding bed into which the knees would sink, but upon the floor 
or a table, for the object of the posture is to elevate the buttocks and 
depress the thorax as much as possible. Ten or fifteen minutes should 
then be allowed to elapse before any efforts are made at reduction. 
In this time the intense congestion which exists in the pelvic viscera 
will greatly diminish. The operator, then taking the cervix into 
the grasp of his index, middle, and ring fingers, pushes the uterus 
firmly and forcibly upward in coincidence with the axis of the inferior 
strait. While the right hand is thus employed the left rests upon the 
back of the patient and steadies her body. No sudden or violent force 
is exerted, but by steady pressure, kept up, if necessary, for fifteen, 
twenty, or thirty minutes, the uterus is restored to its place. 

Few cases will resist this kind of effort at reduction, although some 
may do so. For example, we have already referred to a case in which 
an incarcerated uterus, which appeared upon the point of becoming gan- 
grenous, could not be reduced by the method described, and in which, 
as no time was to be lost, we produced complete anaesthesia, ami then, 
taking the organ firmly in the extremities of the thumb and three fingers, 
we carried it by main force into position. Where oedematous swelling 



390 ASCENT AND DESCENT OF THE UTERUS. 

of the prolapsed organs prevents their reduction, fomentations with 
cloths dipped in a hot solution of liq. plumbi et opii, equal parts, if 

necessary followed by compression by a flannel roller or an elastic- 
bandage, may he necessary, as referred to on the preceding page. 

Methods of Sustaining the Uterus. — Before pursuing any special 
course of treatment for this end the practitioner should endeavor to dis- 
cover the cause of the descent. If it he due to increase in the weight 
of the uterus or to pressure exerted upon it from above, it is evident 
that the indication will be very different from what it would be if the 
cause were traction by a prolapsed vagina. Unfortunately, however, 
after the disease has existed fur some time it is often impossible to fix 
definitely upon the cause : for even if it were originally increase of 
uterine weight, the lengthy inversion of the vagina and stretching of 
the uterine ligaments involved in its descent will have destroyed all 
power in these parts. 

As far as possible, however, the original cause should be a-certained. 
and if it be properly sought for it will in a number of cases be dis- 
covered. For example, suppose that there be no excessive enlarge- 
ment or prolapse of the vagina, no evidence of excessive downward 
pressure, and yet the uterus lies upon the pelvic floor. Strength 
should be given to its normal supports. 

Suppose, on the other hand, that the vagina be found to be in its 
normal state, and the prolapsed uterus to be very heavy, weighing per- 
haps three times what it should. This increase of weight should 
receive especial attention. 

If. again, the insignificant, atrophied uterus of an old woman of 
seventy be prolapsed into a large, flabby, non-contractile vagina, trac- 
tion by this vagina may safely be accredited with the uterine displace- 
ment. 

Lastly, if the common coincidence of rupture of the perineum with 
subinvolution and prolapse of the vagina and uterus be encountered, it 
may be assumed that increase of uterine weight, loss of support, and 
traction have all combined to bring about the issue. 

It should be the care of the physician to keep every one of the 
indications suggested by these factors in mind, and in every case attend 
first to that which concerns the primary and most important : after- 
ward to those which are secondarv and created by the displacement 
itself. 

A very important question offers itself for consideration here : Is 
it possible to give relief in an aggravated case of prolapse in the third 
degree without resort to operative procedure *.' The position has of 
late been taken by high authority that surgery must always be invoked 
as our final resort in such cases, and that less radical treatment should 
be looked upon as palliative and in great degree preparatory. This we 
regard as a doctrine calculated to do great harm, and one which entirely 
misrepresents the true requirements of the subject. We should state 
the matter thus : In a very large majority of cases of prolapse of the 
uterus, whether in the first, the second, or the third degree, relief may 
be obtained without resort to operation : in a certain number of cases. 
where traction by the prolapsed vagina, rectum, or bladder is the cause 



METHODS OF SUSTAINING THE UTERUS. 391 

of the uterine displacement, it should be our chief resource. Now, it 
may be said in reply to this that even if such traction was not a pri- 
mary factor in the displacement, it is always a secondary one, and, like 
a great many theoretical observations, this will carry weight. But it 
is not really a valid argument at the bedside for him who studies these 
cases from a scientific standpoint, however powerful it may be in the 
mind of the empirical gynecologist. If the perineum have lost all 
power, and a loose, flabby condition exist in the vagina from subinvolu- 
tion or hyperplasia the consequence of prolonged congestion, and the 
resulting vaginal, vesical, and rectal prolapse has dragged the uterus 
down, operation merely fulfils the important indication of removing the 
cause of the trouble, and logically presents itself as an important 
resource. If, on the other hand, a heavy uterus presses down of its 
own weight or a normal one is forced down by pressure from above, 
closing the perineum or contracting the vagina by colporrhaphy is illogi- 
cal, unnecessary, and empirical. We would conclude this part of the 
subject by repeating that operative procedure for uterine prolapse 
should be only exceptionally resorted to, and then to fulfil an indication, 
not to comply with a dogmatic rule. 

We have seen numerous cases in which entire relief to complete pro- 
lapse was afforded by means which will soon be mentioned here. So 
complete was this that the patients thus relieved would not listen to the 
proposal of operation. It is true that complete cure was not effected, 
but complete relief was. If the operative procedures for such cases 
w r ere simple, entirely free from danger, and certain as to result, a uni- 
versal resort to them would be indicated ; but they are not so. We 
would not willingly appear to oppose operation in these cases, for we 
favor it and constantly practise it. We merely urge the application to 
them of the ordinary rules which govern the scientific surgeon else- 
where. 

We will now consider in order the methods most appropriate for 
resisting each of the pathological conditions which result in uterine 
prolapse. 

The means adapted to 'prevention of pressure from above are — 
Removing weight of clothing by use of skirt-supporters ; 
Removing weight of intestines by prohibition of tight clothing, use of an 
abdominal supporter, and avoidance of injurious muscular efforts; 
Preventing accumulation of urine and feces. 

The skirt-supporter is merely a pair of suspenders that may be con- 
trived by any woman of ordinary ingenuity, and which enables the 
patient to carry the whole weight of the under-garments upon the 
shoulders. A representation of a very good one will be found in Fig. 
17D. An excellent contrivance of this kind is sold by a Mrs. Richard- 
son of New York, who has supplied many of our patients (P. F. M.). 
It is simply a combination of suspenders and shoulder-braces, which 
support the skirts and draw back the shoulders, and thus aid in keep- 
ing the figure erect. For this latter purpose it is very useful for grow- 
ing girls. Or the skirts may be affixed to a waist, which replaces the 
corset, by buttons, as shown in Fig. 180. 

There are many varieties of the abdominal supporter, some of which. 



392 



ASCEXT AXD DESCEXT OF THE UTERUS. 



unfortunately, are so constructed as to do absolute harm. Should com- 
pression be exerted by them upon the abdomen above the navel, it Avill 
tend to increase pressure upon the uterus, or at least to annul all the 
benefit of that exerted below this point. The principle upon which these 



Fig. 170. 



Fig. 180. 




Skirt-supporter. 




Waist with Button 



upport of Skirts. 



supporters should act is this: they should do just what the patient's 
hands do when she places them above the pubes and lifts the abdomi- 
nal viscera. Some of them are composed simply of bands of thick 
cloth, others are pads or disks of horn or metal, with encircling bands 
like those of the hernial truss. The physician may choose intelli- 
gently, if he only bears in mind what it is that he desires to accom- 
plish by them. 

During the continuance of treatment the patient should be limited 
as to exercise and confined to bed during menstrual epochs, when the 
uterus is known to be heavier than at other times. Should the accident 
have immediately followed parturition, she should be kept in the recum- 
bent posture to favor the accomplishment of involution. 

Means adapted to diminution of uterine weight are — 
Removing polypi, tumors, etc. by operation ; 

Removing uterine inflammation, hypertrophy, and congestion by appro- 
priate treatment : 
Amputation of the neck of the womb : 
Repairing laceration of the neck. 

Sometimes, by applying appropriate treatment to an enlarged cervix, 
the uterus is in time so much lightened by cure of attendant hyperemia 
that relief is effected, but in other cases the hyperemia is so persistent 
and rebellious that these means fail, and resort must be had to more pow- 
erful ones. A lacerated cervix will often prove a focus of irritation, and 
thus a cause of uterine congestion and hyperplasia, which may result 
in descent of the uterus. Under these circumstances closure of the 
laceration will often effect a complete cure, and it should without delay 
be performed. 

In some cases, even when parturition has never occurred, hypertrophy 



ASTRINGENTS AND TONICS. 393 

of the cervix occurs and proves a cause of prolapsus. For this resort 
has been had to amputation of the neck. Huguier of Paris was in 
1848 the first to perform this operation for prolapsus, though it has 
long been resorted to for cancer. Since that time it has been per- 
formed by many others, after methods which will be described later on. 
It must not be supposed that the mere removal of superabundant tissue 
is relied upon for the diminution of uterine weight. It is rather the 
derivative and alterative influences set up by amputation of which the 
surgeon endeavors to avail himself. Besides, the cicatricial contraction 
of the vaginal vault following the operation exerts great influence 
toward retaining the uterus in its normal position. 

Means for strengthening or supplementing uterine supports: 
The recumbent posture ; 
Local astringents and tonics ; 
General tonics ; 

Exercising the retentive powers of the abdomen ; 
Pessaries. 

The recumbent posture, persistently persevered in, accomplishes a 
great deal of good in cases of prolapsus in the first, and sometimes even 
in the second, degree. The buttocks being elevated, the uterus retreats 
from the pelvis and its supports are left entirely at rest. Opportunity 
is thus afforded the weakened tissues to contract, to gain tone and 
strength, and in time to resume their functions. The results of posture 
may be materially increased by simultaneous employment of the follow- 
ing agents : 

Astringents and Tonics. — By these means the pelvic tissues may be 
made to sustain the uterus for a time, and thus, by keeping it out of 
danger of congestion from interference with circulation, opportunity is 
given for removal of engorgement or slight hypertrophy. 

The astringents most commonly employed are tannin, alum, persul- 
phate of iron, and the bark of the white oak. They may be injected 
into the vagina in solution or infusion by means of the ordinary syringe. 
A very excellent astringent under these circumstances is the infusion 
of the sumach-berry, which grows commonly by our roadsides through- 
out the country. The introduction of these agents in the dry pulverized 
state on pledgets of cotton or wool is a far more thorough method than 
by means of solutions or injections. Tannin and iodoform, equal parts. 
or alum and subnitrate of bismuth, 1 to 4, are our favorite remedies. 
They should be inserted at least every other day. 

Tonics may be locally applied by the use of cold hip-baths, douches, 
sea-baths, and by copious vaginal injections of cold water, salt and 
water, or sea-water. 

General tonics, mineral and vegetable, should be employed. Among 
these, ergot, strychnia, and iron may be specially mentioned. Sea- 
bathing is peculiarly beneficial for this purpose, for it not only acts 
locally, but improves the tone of the whole system. In speaking 
generally of the influences which sustain the uterus, the peculiar reten- 
tive power of the abdomen has been mentioned very full v. Habits of 
life with reference to exercise, dress, etc. exert a marked influence over 
this power. The woman who rarely exercises so as to call for full 



394 ASCENT AND DESCENT OF THE UTERUS. 

expansion of the lungs gradually diminishes her breathing power, and 
in the end suffers from atony of the thoracic muscles. This renders 
diaphragmatic action feeble ; the alternate rise and fall of the abdomi- 
nal viscera is lessened ; they settle down upon the pelvic viscera ; and 
the abdominal muscles lose their power and activity. This result is 
produced not only by a life of inactivity, which enfeebles the muscles 
which accomplish thoracic and abdominal respiration by want of use, 
and thus indirectly lessens diaphragmatic action ; any influence which 
directly interferes with the piston-like action of the diaphragm or indi- 
rectly enfeebles by prolonged pressure the thoracic and abdominal mus- 
cles tends to overcome this important function of the abdomen in sup- 
porting and keeping the uterus in good circulatory condition. Should 
any one doubt this, let him examine with Sims's speculum several 
tightly-laced women who since childhood have done all that art could 
do to annihilate this sustaining power of the abdomen, and then the 
same number of women undeformed by the pernicious habit. Let him 
even examine the same woman with and then without corsets, and he 
cannot fail to recognize the slight uterine movement in the one case, 
and the active, vigorous rise and fall in the other. 

As the power of the abdomen is destroyed by pernicious habits, it 
may with perseverance and judicious efforts be restored, and the import- 
ance of striving to accomplish its restoration in all cases of uterine dis- 
placement cannot be too strongly insisted on. This should be done 
first by freeing the trunk from all constriction and weight ; second, by 
causing free action of the diaphragm by general exercises which cause 
this muscle to work vigorously ; and, third, by the practice of special 
exercises adapted to development of the thoracic and abdominal mus- 
cles. As excellent general exercises may be instanced rowing in a 
light boat or upon a rowing machine, 1 practising the "lift cure," the 
use of Goody ear's " parlor gymnasium," or calisthenics. Walking and 
riding, either in a vehicle or on horseback, are excellent in their results 
upon the general health, but they fail utterly in fulfilling the special 
indication required. They improve nutrition and strengthen the mus- 
cles of the lower extremities, but not those of the upper portion of the 
trunk. Their substitution therefore for those just mentioned is an 
error. They may add to the general good accomplished, but do 
not develop either the lost function or the muscles which should 
perform it. 

There are also particular exercises adapted to the especial develop- 
ment of the abdominal muscles, at the same time that they excite an 
exaggerated action on the part of the diaphragm, and tend by that and 
by gravitation to raise the pelvic viscera. For full descriptions of these 
manoeuvres we will refer the reader to the works devoted to the sys- 
tematic development of the muscles of the body. 

Of recent years, following the lead of a layman, Major Thure 
Brandt of Stockholm, who laid aside the sabre to take up the practice 
of manipulation and massage of the muscles of the human body for 
tonic and restorative purposes, Schultze of Jena, the great apostle of 
the mechanical development and treatment of uterine displacements, 

1 Implements for these exercises are on sale in all our large cities. 



PESSARIES. 395 

Profanter, his pupil, and others, chiefly in Germany, have practised and 
loudly advocated the treatment of prolapsus uteri by this method, and 
have reported marvellous results. Aside from the tedious and rather 
delicate nature of the treatment, it is still too new to permit our accept- 
ing it without reserve. The details of the manipulations are too minute 
for reproduction here, and must be read in the original works. The 
method undoubtedly has much in its favor and deserves careful study. 

Pessaries. — The plan of supporting the prolapsed uterus, vagina, 
bladder, and rectum by mechanical contrivances which supplement the 
enfeebled natural supports constitutes a method of great value, and one 
which should never be cast aside. In a great many cases objections of 
advanced age on the part of the patient, want of skill on that of the 
physician, and the uncertainty as to result which attaches to all surgical 
procedures for the cure of prolapse, render a resort to a method which 
relieves very greatly, during even a long lifetime, one which is dictated 
by prudence and good sense. To support four organs, the vagina, ute- 
rus, bladder, and rectum, which are and have been for a long time 
prolapsed, by an artificial mechanical means frequently taxes the skill 
of the ablest gynecologist and sometimes utterly defeats his best attempts. 
Let the general practitioner bear this undeniable fact in mind, and not 
become discouraged by difficulties nor disheartened by repeated fruit- 
less efforts. Let such a one who reads this believe too the assertion 
which we here make, that we advise no instrument merely because it 
has been generally accepted, and that we limit ourselves to the mention 
of those only which we daily employ in practice with good results. 

In employing pessaries for all the varieties of prolapsus of the pelvic 
organs the desideratum is an instrument which" will not distend the 
vagina at the same time that it will support the uterus. Such instru- 
ments as sustain the vagina without distending it, and thus allow it to 
regain something of its former tone and elasticity, are those which 
should be, as far as possible, selected. The great functions which, in 
the majority of cases, are required of a pessary in prolapsus are these : 
first, to supplement the action of the utero-sacral ligaments, the chief 
factors in sustaining the uterus; second, to keep the vagina, bladder, 
and rectum in place, so as to prevent them from perpetuating the ute- 
rine displacement by traction. 

We have already said that he who treats this condition, in any of 
its varieties, by replacement and support by a pessary must frequently 
meet with insuccess. Is it not illogical to suppose that by any mechan- 
ical contrivance heavy, congested, and prolapsed organs, often four in 
number, very generally three, can be, without preparation or the use 
of allied means, kept at once in normal position ? Yet such a result 
is often anticipated. Before resorting to a pessary at all it is a good 
plan to keep the patient in the recumbent posture for a few days, or if 
possible a week, with the foot of the bedstead elevated twelve inches 
for the purpose of allowing congestion to pass off. During this time 
mild cathartics should be given to further this end by removal of fecal 
matter and stimulation of hepatic circulation, and the vagina should 
be systematically and copiously irrigated with astringent fluids, or packed 
with tampon, covered with dry astringent powders, to harden its tissues 



396 



ASCENT AND DESCENT OF THE UTERUS. 



in preparation for a pessary, to effect support of the uterus, bladder, 
and rectum by a re-establishment of its sustaining power, and to cause 
contraction in its distended superficial blood-vessels. This time is not 
wasted, for the case is sure to be a lengthy one, and at the end of it 
the patient is much better able to begin treatment of a mechanical kind 
without meeting with mishaps, which in the commencement dishearten 
and discourage her. Nowhere is the statement more true than here 
that a good beginning advances us halfway to success. 

The patient having risen, all of these means, except recumbency, 
should be continued throughout treatment, and others which are adju- 
vants to the pessary should be adopted, as, for example, removal of 
weight of clothing ; avoidance of deleterious muscular efforts, long 
standing, and constrained postures ; diminution of weight of uterus ; 
development of retentive power of the abdomen ; and others which 
have been already enumerated. Having attended to all these points, 
the pessary presents itself as a valuable resource by which to complete 
and effect restoration of the parts: without attention to them it is, as 
a rule, too feeble to accomplish, unaided, the desired result. 

Let us suppose that we are dealing with a case of prolapse in the first 
or second degree, what pessary should we choose ? This will depend upon 
the amount of weight to be sustained. If this be great, subinvolution 
of the uterus existing and depressing the organ, very possibly no inter- 
nal pessary will succeed ; if it be moderate, almost any one of this list 
will do so : Meigs's elastic ring, Hodge's, Smith's, Hewitt's, or Thomas's 
pessaries, all of which are shown by diagrams in connection with retro- 
version. None should be used which distends the vagina, and that 
employed should be worn without any sense of discomfort ; should be 
kept clean by irrigation with astringent fluid every night or night and 

morning ; and should be examined 
at intervals by the physician to 
make sure that it is not injuring 
the tissues. 

If the great weight of the uterus 
renders these pessaries, which pass 
entirely into the vagina, ineffectual, 
or should the case be one of pro- 
lapse in the third degree, others, 
which are in part external and in 
part internal, should be employed. 
We very rarely attempt to sustain 
a completely prolapsed uterus by an 
internal pessary, because we usually 
despair of success, and because we 
have known such evil consequences 
result from them in such cases that 
we are unwilling to let the patient 
pass out of our sight with one in 
place. An exception to this rule 
must be made in favor of the Gehrung pessary, already described 
under Cystocele (see p. 177 and Figs. 64, 65), which we have found of 



Fig. 181. 




Cutter's Prolapsus Pessary in Position. 



PESSARIES. 397 

incalculable benefit in those cases where the anterior vagina] wall and 
bladder are chiefly prolapsed with the uterus, the descent of the former 
organs having in all probability preceded, and to some extent produced, 
the prolapse of the latter. Here we have often found a well-fitting 
Gehrung to retain both cystocele and uterus in perfect position, without 
pain or inconvenience to the patient other than the usual occasional 
removal of the pessary to prevent its cutting or eroding the vagina. 

In other forms of prolapsus, where the prolapse of the posterior 
vaginal wall predominates or the whole vagina is prolapsed, it is 
usually safer, more effectual, and more comfortable for both physician 
and patient that she should wear an instrument which she can remove 
at will, allow the parts to rest during the hours of recumbency, and 
replace upon rising. 

There are three methods by which such support may be furnished : 
by a stem curling over the perineum, by one passing out of the vagina 
over the symphysis pubis, and by one ending at the middle of the vul- 
var opening and resting upon a bandage passing beneath it. Of these 
plans, the best is the first, and the next in merit the second. The 
third is objectionable on account of the want of some point of support 
against which to fix the distal extremity of the stem and to prevent 
motion in it. 

Fig. 182. Fig. 183. 





Cutter's Prolapsus Pessary. Thomas's Modification. 

No pessary with which we are acquainted so universally answers the 
indications of supplementing the action of the utero-sacral ligaments 
and sustaining the prolapsed vagina, rectum, and bladder as Thomas's 
modification of Cutter's admirable pessary, shown in Figs. 182 and 183. 
The cup at its upper extremity receives the cervix uteri, and the sim- 
plicity of the instrument enables the patient to remove and replace it 
with perfect facility. This should be done in the recumbent posture 
upon retiring at night and rising in the morning. 

Unless great caution is observed all supporters which forcibly retain 
the uterus in situ will inevitably produce erosion and ulceration of the 
part of the cervix or vagina against which the strongest pressure is 
exerted. Hence they are really all objectionable, and merely tolerated 
for want of something better. 

Means for Preventing Traetion by the Vagina : 
Perineal support ; 



398 ASCENT AND DESCENT OF THE UTERUS. 

Perineorrhaphy ; 
Colporrhaphy. 

Perineal Support. — We have already pointed out the important 
function of the perineal body in closing the mouth of the vagina and 
offering a buttress for the support of its walls. When rupture of the 
perineum occurs its sphincteric powers are destroyed, and the result is 
sago-ins; f one or berth columns of the vagina and coincident descent 
of the uterus. By firm pressure at the weak spot, by means of a pad 
or cushion filled with hair, cotton, or air, and combined with an abdomi- 
nal supporter, to which it may be attached, partial relief is sometimes 
obtained. 

Perineorrhaphy . — Much more complete and permanent support may 
be given to the vagina, and prolapse of its walls be much more certainly 
obviated, by restoration of the perineal body by the operation of perin- 
eorrhaphy. If the uterus be not very heavy this operation often 
proves a very excellent means of relief, for it removes the tractile 
power which pulls down this organ, and thus the cause of the accident 
is taken away. But this operation, although efficient in these cases, is 
not likely to prove so where so heavy a weight as a much-enlarged 
uterus requires support. 

It must not be supposed that in cases of prolapsed vagina perineor- 
rhaphy is limited to instances in which the perineal body is ruptured. 
It is equally applicable to those in which it has lost its power from 
any of those influences which are mentioned in the chapter upon the 
Perineum, such as subinvolution, subcutaneous separation of the bilat- 
eral perineal muscles, etc. etc. 

In all cases, to be effectual, perineorrhaphy must restore the lost 
organ, the perineal body, and not simply shut the evil from sight by 
drawing before it a thin and useless curtain which extends from the 
fourchette to the anus. 

Should this operation not be sufficient to remove traction, colpo- 
perineorrhaphy, or anterior or posterior colporrhaphy, or a combination 
of these, may be practised. 

For these procedures the reader is referred to chapters which have 
gone before. 

By these means traction is taken away from the uterus, and if this 
was the cause of its prolapse relief will probably follow, but it is 
never safe to promise a good and permanent result from any of the 
operations of colporrhaphy. If in a case of laceration of the cervix, 
relaxation of the vagina, and complete distension or rupture of the 
perineum the patient is willing to submit to three operations — operation 
upon the cervix, colporrhaphy upon anterior and posterior walls, and 
closure of the perineum (trachelorrhaphy, Stoltz's and Hegar's opera- 
tions, for instance) — cure will often be complete and permanent. This 
is a trying ordeal, both mentally and physically ; nevertheless, most 
women affected by prolapsus in the third degree would unhesitatingly 
accept one of even greater severity with the prospect of cure. All 
these operations can usually be performed at one sitting, and we have 
had many excellent results by thus combining them. 

Not only have efforts of this kind been made for narrowing the 



OPERATIONS FOR PROLAPSUS UTERI. 399 

vagina and creating an artificial cicatricial anterior or posterior col- 
umn for the support of the uterus ; the actual cautery, mineral acids, 
escharotics, ulceration created by galvanic pessaries, and sloughing 
produced by pressure by forceps, have all been tried for the accom- 
plishment of the much-desired end. All these methods have the dis- 
advantages of proving excessively painful after anaesthetic influence 
has passed off, and of being more unmanageable and less certain in 
their results than those here described. Hence they have been entirely 
abandoned, and at the present day only well-planned plastic opera- 
tions, designed to narrow the vagina and restore the perineum, and 
thus retain the prolapsed organs on proper mechanical principles, are 
recognized and practised. Numerous methods of operation have been 
devised, nearly every prominent operator having his own favorite design 
for the operative cure of prolapsus uteri. The combination which has 
done us the best service is that mentioned above ; but Martin, Bischoff, 
Fritsch, Lefort, Simon, and others, mostly Germans, have devised inge- 
nious, more or less complicated, and more or less successful methods, 
which our space prevents us from describing in detail. (For full descrip- 
tions see Martin 1 and Fritsch. 2 ) One objection to all these plastic ope- 
rations is the tendency of the cicatrices to stretch after a time, and 
thereafter the return of the displacement. 

Within the last few years two other operations have been devised on 
an entirely different principle for retaining a prolapsed uterus in place 
after its reposition. One consists in shortening the round ligaments 
through an incision over the external ring on each side of the pubis, and 
is known by the name of its inventor (or at least perfector), Dr. William 
Alexander of Liverpool. We have employed it in several cases of pro- 
lapsus with very fair success, both as to immediate and permanent results, 
when the uterus was not enlarged. But we have always added to it the 
plastic operations on cervix and vagina in order to ensure absolute suc- 
cess. [This is my personal opinion and experience, with which Dr. 
Thomas does not entirely agree. — P. F. M.] 

The other operation is of still more recent date, and comprises the 
attachment of the fundus uteri to the anterior abdominal wall by means 
of sutures passed through the whole thickness of the wall and deep into 
the fundus, which has been exposed by a short incision. Miiller of 
Berne has performed this operation, we believe, more frequently than 
any other operator, but has given it up because the attachment yielded 
after a time and the prolapse returned. The same has been our experi- 
ence in one case, and another case we lost from " intestinal paralysis." 
We are inclined for these reasons to discountenance this operation. Both 
these methods will be again referred to in the chapter on the treatment 
of retro-displacement of the uterus. Finally, mention should be made 
that the prolapsed uterus has been successfully removed entire in a num- 
ber of cases by Leopold, Martin, and other bold and enthusiastic ope- 
rators. 

1 hoc. cit. a Diseases of Women, Eng. trans., Win. Wood & Co., 1883. 



400 ANTERIOR DISPLACEMENTS OF THE UTERUS. 



CHAPTER XXIX. 

ANTERIOR DISPLACEMENTS OF THE UTERUS. 

Ante version. 

Definition and Frequency. — This disorder of position consists in an 
anterior inclination of the uterus, so that the fundus approximates the 
symphysis pubis and the cervix retreats into the hollow of the sacrum. 
Although not so frequent as its kindred condition, anteflexion, it is by 
no means of rare occurrence. At times it presents itself as an annoy- 
ing complication of areolar hyperplasia or fibroid growths, while at 
others it is produced without any alteration existing in the uterine 
parenchyma. 

We meet with versions very commonly in the non-puerperal state, 
although it must at the same time be admitted that anterior displace- 
ments generally assume the character of flexions. To give some idea 
of the relative frequency of the various anterior and posterior displace- 
ments, we present the following tables. The first table is one con- 
structed from a valuable statistical report by Dr. Meadows : 

Number of cases of displacement examined 84 

u „ <- • j- -\ r S Retroflexion ... 34 

posterior displacement . . oz < -r, , • -. Q 

v * (Retroversion . . .18 

" anterior displaces, . .32 {£££*£ | | | '» 

It is impossible to reconcile the discrepancy of the results obtained 
by statistical evidence accumulated by different observers, Thus, for 
example, out of 339 cases of displacement recorded by Nonat, 1 the 
following were the number of anterior and posterior inclinations : 

Anteversion 135 

Anteflexion 33 

Retroversion 67 

Retroflexion 14 

"Anteversion," says Klob, 2 "in general is a rare form of displace- 
ment, and occurs much less frequently than retroversion." 

Emmet, out of 555 cases of version, found 236 to be anteversion, 
and 295 retroversion. 

Munde 3 gives the following proportions in 895 cases of displace- 
ment: 

Anteversion 112 

Anteflexion 295 

Retroversion 348 

Retroflexion (uncomplicated) 55 

1 Mai. de V Uterus, p. 416. 2 Klob, Patholog. Anat, p. 68. 

3 " Curability of Ut. Displ.," Am. Journ. Obst, 1881 ; Minor Surg., Gynecology, p. 394. 



ANTE VERSION OF THE UTERUS. 401 

the remaining 85 cases being instances of latero-version and latere- 
flexion and combinations of several varieties. 

Winckel 1 found in 233 cases 45 anteversions and 188 anteflexions, 
or 1 to 4 ; and Schultze, 79 : 296, about the same. 

Subjects of this character belong to that class upon which reasoning 
and theorizing accomplish no good, but rather the contrary. The only 
way in which they can be settled is by carefully-collected statistics, and 
one would suppose that this method would be conclusive. Yet we see 
in the present case how far this is from being the fact. Dr. Meadows's 
most frequent displacement is M. Nonat's and Scanzoni's least frequent ! 
Nothing but discrepancy and doubt results from the comparison of the 
figures of these three conscientious observers. " There is nothing," 
said Sydney Smith, "so unreliable as figures, except facts." After 
such a comparison of statistical evidence one feels inclined to agree 
with him. 

A possible explanation of this discrepancy may be sought in the 
fact that, as frequently a version and a flexion both exist at the same 
time (particularly in retro-displacements), the more prominent condition 
was chosen as the designation of the case. Hence, retroflexion appears 
less frequently than the usual primary displacement, retroversion. 
Such, at least, we know to have been the reason for the comparatively 
small number of retroflexions (55), as compared with retroversions 
(348), in Munde's figures. We certainly feel convinced that ante- 
version, except in the puerperal condition, is much less frequent than 
anteflexion. 

The normal position of the uterus is one of slight anteversion, the 
axis of the body corre- 
sponding with that of the FlG - 184 - 
superior strait, which is a 
line running from the um- 
bilicus, or a little above it, 
to the coccyx. 

The degree of this for- 
ward inclination may be so 
increased by slight causes 
as to constitute a morbid 
state. As to the line which 
separates what is normal 

from what IS abnormal, It Anteversion of Extreme Degree (Beigel). 

is impossible to lay down 

any exact rule ; experience must be our guide. In general terms we 
may say that when the long axis of the uterus is found lying across 
the pelvis, the fundus near the symphysis pubis, and the neck in the 
hollow of the sacrum, anteversion exists! 

Predisposing Causes. — The predisposing causes of this affection are 
parturition, enfeebled muscular condition, habits of indolence and inac- 
tivity, and loss of tone in the abdominal walls. 

The exciting causes may thus be presented : 

1 Loc. tit, p. 292. 
26 




402 ANTERIOR DISPLACEMENTS OF THE UTERUS. 

Influences increasing the Weight of the Uterus. — Congestion ; 
Hypertrophy or Hyperplasia ; Subinvolution ; Fibroids ; Pregnancy. 

Influences forcing the Fundus directly Forward. — Violent efforts ; 
Abdominal tumors ; Tight clothing. 

Influences enfeebling Uterine Supports. — Ruptured perineum ; 
Relaxation of ligaments ; Destruction of the retentive power of the 
abdomen ; Cystocele. 

Influences dragging the Fundus directly Forward. — False mem- 
branes ; Prolapsus vaginae ; Cystocele ; Shortness of the round liga- 
ments (?) ; Anteflexion. 

A large number of cases will be found due to areolar hyperplasia; 
a number by no means inconsiderable to fibrous tumor ; some of the 
most irremediable cases to false membranes, either binding; the fundus 
to the bladder or attaching the cervix to the rectum (possibly contrac- 
tion of the vesico-uterine or sacro-uterine ligaments) ; many to cysto- 
cele, which takes away support at the same time that it produces trac- 
tion ; while a few will exist without other apparent cause than direct 
pressure from some power which forces down the abdominal viscera 
upon the fundus. The last cause is much aided by laxity of the abdomi- 
nal walls, which robs the viscera of support. 

One fruitful source of the condition is unquestionably the gradual 
destruction of the retentive power of the abdomen by habits which 
engender atony of the thoracic and abdominal respiratory muscles and 
enfeeblement of the action of the diaphragm. 

Symptoms. — In a large number of cases anteversion will be found 
to exist without creating any disturbance either constitutional or local. 
By pressure of the os against the posterior vaginal wall anteversion 
may induce dysmenorrhea and sterility, and by pressure of the fundus 
against the bladder and the cervix against the rectum these viscera are 
irritated and interfered with in their functions. The bladder more 
especially suffers, sometimes a state bordering upon cystitis being 
engendered. Pressure upon the rectum more rarely produces tenesmus 
and a painful, irritable state. 

[In exceptional cases it is surprising to see to how great an extent loco- 
motion is affected by this condition. My experience furnishes me with four 
cases in which patients were for long periods confined to bed or the lounge 
on this account. In one of these the patient had not left the house for 
four years ; in another she had scarcely assumed the upright posture for 
eight months ; the third was the counterpart of the second ; while in the 
fourth the patient for twelve years had never walked over a quarter of a 
mile without serious "inconvenience. In each of these cases positive proof 
was afforded me of the agency of anteversion in producing the disability 
which existed, by its removal when the uterus was properly sustained by 
an anteversion pessary, and by relapse at once recurring when without 
her knowledge she was left without it. Not one of these women was suffering 
from that hysterical condition which so often misleads the physician as to 
the results of remedies. — T. G. T.] 1 

1 [My personal experience obliges me to disagree to some extent with this view, 
since I can recall but few cases where an uncomplicated anteversion produced serious 
symptoms of any kind. Only when the uterus was enlarged by hyperplasia or fibroids, 



ANTE VERSION OF THE UTERUS. 



403 



Course, Duration, and Termination. — Even if the exciting cause 
of the condition be removed, it will usually continue, for the broad and 
utero- vesical ligaments have by long distension become stretched and 
enfeebled, while there has been simultaneous contraction in the utero- 
sacral ligaments from long disuse. The first fail to aid the fallen organ ; 
the last help to keep it out of position by lifting the cervix up against 
the rectum. Sometimes cure is effected by pregnancy, the displacement 
disappearing as involution is accomplished. Usually, however, unless 
the exciting cause of the condition be removed and the organ be kept 
in proper position for a year or more, the displacement will continue 
unabated. 

Varieties. — Anteversion may be complete or partial. While there 
are three degrees of retroversion and of prolapse, there are but two of 
this displacement, for the axis of the uterine body is naturally inclined 
so much forward as to prevent us from including slight increase of 
inclination under the head of disease. 

Fig. 185 will show the varieties referred to ; an inclination of 45° 
representing the first degree, or partial anteversion, and that of 90° the 
second degree, or complete anteversion. 

Fig. 185. 




The Degrees of Anteversion. 



Diagnosis. — When in a case of this displacement vaginal touch is 
practised, the patient lying on the back, the index finger passed into 
the fornix vaginre discovers that the cervix is absent. A rapid inves- 
tigation will prove that it is not to be found in the pubic or lateral 

or when a prolapsus of the first degree existed at the same time, were the sensations 
of suprapubic weight, bearing down, and of vesical irritation complained of. And 
only such eases, as a ride, required mechanical support. — P. R M.] 



404 ANTERIOR DISPLACEMENTS OF THE UTERUS. 

regions of the pelvis, and deep exploration with two fingers will dis- 
cover it high up in the hollow of the sacrum. The finger being then 
passsd toward the pubes will come in contact with a hard ridge, which 
will run toward the symphysis. Conjoined manipulation will prove 
this to be the body of the uterus and complete the diagnosis. Should 
further evidence be required, the uterine probe, very much curved, may 
be passed into the cavity, though this is rarely necessary and always 
difficult. 

Differentiation. — Capuron tells us that Levret mistook the first case 
he saw for stone in the bladder, operated for this, and sacrificed the life 
of the patient. In spite of such a grave mistake at the hands of so 
great an authority, it may be stated that there is no diseased condition 
with which this should be confounded. The disease inducing the dis- 
placement may not be recognized, or some serious error may be made 
as to its nature, but that does not concern the present subject. The 
recognition of the mere fact of the ante version is never difficult if 
proper diagnostic means are brought to its elucidation. 

Prognosis. — The prognosis as to any serious injury which will arise 
from the displacement is decidedly good, although there are many incon- 
veniences and discomforts connected with it — such, for example, as vesi- 
cal and rectal irritation, neuralgia in consequence of compression of the 
nerves, and difficulty in locomotion ; none of these, however, go on to 
a dangerous degree of development. If the condition be not treated by 
mechanical means, it will prove entirely incurable ; but by these the pros- 
pect of great improvement, and even of complete cure, is very good. 
Important and early evidences of improvement resulting from mechanical 
treatment are frequently obtained in disappearance of dysmenorrhea and 
sterility. It is often difficult to remove the exciting cause of anteversion, 
and even should this be accomplished the uterus is so prone to retain the 
abnormal position in which it has long been kept that great difficulty 
attends its retention in normal position. One of the reasons for this is 
the fact, already stated, that the uterine ligaments readily alter their 
proportions under certain influences. Thus during pregnancy they are 
all elongated ; in posterior displacements the utero-sacral ligaments are 
stretched ; and in anterior inclination the utero-vesical ligaments are 
similarly affected. As the antithesis of this fact, prolonged absence of 
function causes contraction in these structures ; thus in anteversion 
the utero-sacral ligaments are generally shortened, and there is no 
doubt that the round ligaments are similarly altered. 

Anteflexion. 

Definition. — This, which is one of the most frequent of all uterine 
displacements, consists in a bending of the organ so that the fundus, 
the cervix, or both, are bent more or less sharply forward. 

Varieties. — There are three forms of anteflexion : first, corporeal 
flexion ; second, cervical flexion ; third, cervico-corporeal flexion. 

1st. The cervix being normal in position, the body is flexed; 
2d. The body being normal in position, the cervix is flexed ; 
3d. Both are flexed forward. 



ANTEFLEXION OF THE UTERUS. 



405 



The lines represented in Fig. 188 will serve to show the deviations 
which may affect the axes of both body and cervix. 

These varieties are neither arbitrary nor unnecessary. The existence 
of each may readily be verified at the bedside, and treatment should 
always be materially modified by the peculiarity of the deviation. It 
appears to us that a neglect of them and the fixation of attention upon 
flexure of the body alone has seriously retarded progress in treatment. 
No one can intelligently treat anteflexion without regard being had to 
the variety of the disorder to which he is called upon to adapt his 
mechanical appliances. 

Fig. 186. 




Anteflexion of the Uterus. 

Besides, there is a not uncommon form, usually congenital, in which 
the cervix is flexed upward and the body forward, while the whole ute- 
rus is tipped backward on its longitudinal axis, as though it swung on 
a horizontal pivot. This condition is called retroposition with ante- 
flexion. 

Symptoms. — The necessity of these displacements may exist for 
years without the development of symptoms. In aggravated cases. 
however, obstruction to venous return at the point of flexure produces 
congestion, which increases the displacement, disturbs the nervous sys- 
tem, and disorders uterine functions. Then the following symptoms 
may develop themselves : Pain over hypogastrium ; Irritable bladder ; 
Dysmenorrhoea ; Sterility. 

In some cases there is a morbid and invincible aversion to walking, 
partly arising from physical and partly from mental causes. We have 



406 



ANTERIOR DISPLACEMENTS OF THE UTERUS. 



in several cases seen women who had been bedridden for three and four 
years rapidly restored to their powers of locomotion by restoration of 
the uterus to position and its retention by an efficient pessary. 

Dr. Hewitt mentions the retention of secundines after abortion in 

Fig. 187. 




Retroposition with Anteflexion. 
Fig. 188. 



{ r l 



Normal Axis. 



First Variety of 
Flexion. 



Second Variety of 
Flexion. 



Third Variety of 
Flexion. 



cases of anteflexion, and their putrefaction in utero, and advises as 
treatment restoring the organ to place, when expulsion at once occurs. 

The number and severity of the symptoms produced by anteflexion 
were formerly estimated at a much larger figure, as can be seen by refer- 
ring to the last edition of this w T ork. We have already stated our 
change of opinion since then. Besides dysmenorrhea and sterility in 
the graver forms, we at present find but few cases of uncomplicated 
flexions which produce either severe symptoms or call for treatment of 
any kind. 

Physical Signs. — As the finger passes into the vagina and touches 
the cervix nothing abnormal will usually be discovered. But as it sweeps 
alono- the anterior wall of the uterus, about the os internum a protuber- 



ANTEFLEXION OF THE UTERUS. 407 

ance will be met with which presses upon the bladder. The finger 
which has thus far explored being kept in contact with this mass, the 
disengaged hand should then be laid upon the abdomen and made to 
depress the anterior abdominal wall so as to approximate the finger in 
the vagina. By this means the shape, size, and sensitiveness of the 
body may be ascertained, and usually, unless inflammatory fixation is 
present, the examining fingers can straighten out the uterus. Should 
the diagnostician, however, still be in doubt whether the enlargement 
may not be one due to fibrous tumor or an ante-uterine exudation, 
this point can be settled by placing the patient on the side, introducing 
Sims's speculum, and gently probing the uterus to the fundus. Giving 
to the probe the curve which by vaginal touch he has been informed is 
that of the uterus, he carefully passes it in. Should it not proceed 
without obstruction, he withdraws it, alters the curve, and tries again. 
Having succeeded in introducing it, he learns the course of the uterine 
canal, its length, and the sensitiveness of its walls. Should the probe 
have entered the mass felt through the vagina, that mass is the uterine 
body. Should it go in the normal axis or backward, it is not the ute- 
rine body, but some growth in contact with it. In pure cervical flexion 
the neck will be felt sharply bent forward, and in the double form 
both neck and body will be found flexed. 

Prognosis. — As regards the relief of the symptoms the outlook is 
excellent. Dysmenorrhea can usually be relieved; conception often 
follows treatment ; hypogastric pain and irritable bladder will seldom 
resist proper elevation of the fundus uteri by an abdominal or vaginal 
support. But so far as restoring a sharply anteflexed uterus to its 
normal shape, and keeping it so after treatment has been discontinued 
or the supporter removed, that, we are compelled to admit, is in our 
experience an impossibility. 

Practically, therefore, we know of no one form of treatment that 
will permanently cure a badly anteflexed uterus. 

Treatment of Anterior Displacements. — Nature possesses the 
only means, and that is the physiological tissue-changes occurring 
during pregnancy and following parturition, through which the angle 
of flexion may possibly become effaced and the uterine canal remain 
straight and wide. Hence the importance of adopting measures to 
bring about this desirable occurrence. As already stated, in our 
present opinion, based on more recent observations, these displace- 
ments produce symptoms and require positive treatment only when in 
aggravated forms or when complicated with other diseases, such as pro- 
lapsus, endometritis, hyperplasia, fibroids, laceration of the cervix, etc. 
We should therefore be careful first to ascertain the precise influence 
the displacement has on these complications or the reverse, and then 
proceed to treat either the displacement or the complications as the ease 
may be. Of course the old rule, first to remove the cause of the dis- 
ease if possible, should be observed, at the same time, however, not 
forgetting to do what is best for the symptoms while waiting to effect a 
radical cure. Hence a pessary may be at once required to relieve present 
pain while later measures are being adopted to cure the complications. 

Means for Reduction. — In the restoration of an anteverted uterus 



408 ANTERIOR DISPLACEMENTS OF THE UTERUS. 

to its place difficulty will rarely be experienced, for, unlike retrover- 
sion, the displacement does not often become complete. Even when 
it does so, reduction may be easily accomplished by the finger, the 
bladder having been previously emptied. The fundus can then be 
grasped with the other hand through the abdominal walls, and reduc- 
tion at once completed. In difficult cases the sound may be employed 
as a repositor, but we can scarcely recall a case where the fingers alone 
failed to effect the reduction of either an anteflexed or anteverted 
uterus. 

Fixation of the body of an anteflexed uterus being extremely rare, 
we have never had occasion to employ one of the instruments devised 
for this purpose (Elliot's and Jennison's repositors, "Wallace's spring tent), 
which really find such utility as they may possess in retroflexions. 

Some practitioners rely for cure upon the daily restoration of an 
anteverted or retroverted uterus, but hopes thus based will usually prove 
delusive. Where the version is complete and sudden a return to the 
normal position may be final, but rarely have we seen it so result where 
the displacement was incomplete and chronic. 

Should it be found necessary to use the sound as a repositor, it is 
introduced to the fundus, not much curved, but as straight as it can 
be made to pass ; the handle being held in one hand, the tips of the 
fingers of the other should be pressed against the shaft of the sound 
near the middle, and, they being made a fulcrum, the handle should be 
carried to the symphysis. By this manoeuvre the flexed fundus is 
elevated, and at the same time carried toward the hollow of the sacrum. 
This point being reached, the sound should be very gently rotated, and 
complete retroversion with partial retroflexion of the uterus accom- 
plished. This should be done with the utmost gentleness and as we 
have described, not by a sudden rotation of the flexed organ, which 
forcibly sweeps the fundus around the superior strait of the pelvis. 

A repetition of this manoeuvre a number of times, at intervals of 
one or more days, will render the straightening of the uterus more easy 
at each time. But, of course, as soon as the sound is withdrawn the 
flexion returns, and means will have to be adopted to keep the uterine 
axis as straight as Nature designed it to be. These means are twofold : 
that which by uterine tents and the intra-uterine stem forcibly straight- 
ens the bent organ ; and that which by the knife or scissors renders 
the canal straight without reference to the relations of neck and body. 
Such cases being commonly congenital, one wall is well developed by 
excessive growth, while the other is dense, rigid, atrophic, and unyield- 
ing. They may, however, result from prolonged accidental flexion, 
with development of slight attacks of peritonitis ; even without the 
last, indeed, for cicatricial retraction of the atrophied section of con- 
nective tissue has been found by Klob under these circumstances. 

One of the most effectual means of meeting the difficulties of (supposed) 
irreducible flexion is the use of the spring tent of the late Dr. Ellerslie 
Wallace of Philadelphia. He passed through a canal made in a piece 
of carbolized sponge a small piece of Avatchspring and compressed the 
sponge, so as to make the tent curved, as represented in Eig. 189. 

In this condition it was passed into the flexed uterus, and as the 



ANTEFLEXION OF THE UTERUS. 409 

sponge softened the spring erected itself and strengthened the uterus. 
AH the dangers attending the use of sponge tents attended the use of 
this, but no more. It may be practised once a week until three or four 

Fig. 189. 




Ellerslie Wallace's Spring Tent. 

tents are used, or it may be used once and be followed by the intra- 
uterine stem. 

We have retained this description merely as a curiosity, in order to 
show what desperate means were formerly thought necessary to cure 
conditions which were either incurable or required no treatment what- 
ever. Nowadays, no well-instructed gynecologist would think of expos- 
ing a patient to the dangers of septic infection, or of lighting up again 
the peritonitis which originally caused the irreducible flexion by using 
such a contrivance. A much better and safer method of straightening 
and dilating a flexed uterine canal is by inserting a bent moist laminaria 
or tupelo tent, and leaving it until it is fully expanded, or by repeated 
forcible dilatation with a Palmer or Goodell dilator. 

One very important fact, however, which should be constantly borne 
in mind in connection with anteflexion is, that there is a class of cases 
of irreducible flexions which is incurable. The practitioner, unwilling 
to admit this to himself or not appreciating the fact, begins treatment 
from a conventional idea that such is his duty. But the case proves 
far too obstinate for the ordinary local treatment ; tents will not cure 
it, and trachelotomy, not fully meeting the mechanical indications, fails 
likewise. If the patient passes the ordeal without being attacked with 
peritonitis or cellulitis, she in time gives up all efforts at cure or seeks 
the advice of another physician. 

Another class of cases is that which does not require any treatment, 
for the flexion produces no special symptoms, or if dysmenorrhea or 
sterility do call for interference, no remedies should be employed which 
would be likely to cause inflammation and aggravate instead of improve 
the condition. 

Means of Retention in Position of a Uterus Anteriorly Displaced. — 
In every case of anterior displacement let the practitioner endeavor to 
find out which is the main element concerned in its production, bur at 



410 AXTERIOR DISPLACE MEXTS OF THE UTERUS. 

the same time let him remember that this one has almost surely devel- 
oped others which are scarcely less important as factors. In most cases, 
therefore, he will be called upon to direct his attention to all forms of 
the pathological influence about to be mentioned. 

All increased weight of the uterus should be treated by appropriate 
means : inflammation and its results by methods already mentioned, 
hyperplasia and hypertrophy by means adapted to their management, 
and laceration of the cervix by trachelorrhaphy, etc. The fulfilment 
of this indication alone will sometimes effect a complete cure of antever- 
sion. "Whether it does so or not, the next should always receive attention. 

Pressure from above should be removed by carrying the weight of 
the clothing upon the shoulders by skirt-supporters ; pressure of the 
intestines, by prohibition of tight clothing, the use of an abdominal 
supporter, and the avoidance of injurious muscular effort. 

The dorsal decubitus in cases occurring suddenly, as, for example, 
during early pregnancy or after labor, is of great value, and even in 
chronic cases is an important adjuvant to treatment by pessaries. In the 
commencement of such treatment at least it should be always adopted 
for two or three hours every day at mid-day, for the purpose of afford- 
ing a temporary rest to the parts. 

In proportion to the disadvantages resulting from corseting the upper 
segment of the trunk are the advantages to be derived in these cases 
from thus acting upon the lower. "When the abdominal walls are lax 
and yielding, and do not properly sustain the viscera, they call upon the 
the fundus uteri and tend to produce and keep up anterior obliquity. 

No one can deny that by a well-fitting abdominal supporter tone is 
given to the lax walls, and that the intestines, not the uterus, are sus- 
tained. We have already stated that many are prejudiced against this 
means and decry it as absolutely injurious ; but we see it too plainly 
and certainly productive of good results in daily practice to admit of 
any doubt in our minds concerning it. Dr. J. C. Nott offered a very 
plausible explanation of the fact that in some women benefit follows 
the use of abdominal supporters, while in others absolute injury results 
from their employment. " If the patient be emaciated," said he, "and 

Fig. 190. 




Suprapubic Pad of Wood or Cork. 



the abdominal walls retracted or even flattened, the supporter will 
depress and not sustain the uterus. On the other hand, if the woman 
be corpulent the greatest support will be yielded by its application." 
W T e have employed for this purpose with very great advantage an 
abdominal pad or truss which is at the same time simple, inexpensive, 
and efficient. It consists of an ovoid block of cedar, pine, or cork, 



ANTEFLEXION OF THE UTERUS. 



411 




five inches long by four inches wide. This is convex upon the surface 
to be placed next the body, and flat on the opposite side, and is held in 
place by an elastic band or slender strip of steel covered with leather, 
like an ordinary male truss. The pressure made 
resembles that of the hand, and as soon as pa- 
tients become accustomed to it, which, it should be 
borne in mind, may take a little time, gives great 
comfort. A very efficient abdominal bandage is 
shown in Fig. 191, and is known as the Thomp- 
son supporter. It is knit, and therefore cool, airy, 
and elastic. 

Traction upon the uterus from' below, if found 
to exist, should be removed by perineorrhaphy 
alone or combined with colporrhaphy, or it may be 
obviated by the use of a pessary which sustains 
vagina, uterus, and bladder. Abdominal Supporter. 

Fig. 192 shows how loss of power in the peri- 
neum will result in prolapse of the anterior vaginal wall, how the bladder 
will in consequence prolapse, and how the upper portions of the uterus 
will follow it, anteversion resulting, and how perfect repair of the peri- 
neum, together with anterior and posterior colporraphy if necessary, will 
remove all traction from the uterus and allow it to resume its place in 
the pelvis. 

Loss of the normal supports of the uterus should be overcome by 
the use of general and local tonics (which act on general tonic princi- 
ples), developing the reten- 
tive powers of the abdomen, 
and by the use of pessaries. 
Astringent vaginal injec- 
tions, astringent tampons, 
sea-bathing, and the internal 
use of vegetable and min- 
eral tonics are unquestion- 
ably of value. 

By the development of 
the retentive power of the 
abdomen a great deal can 
be done for replacement and 
support of an ante verted 
uterus. Every morning and 
evening the patient should 
place herself flat upon the 
back upon her bed, with the 
hands clasped over the head 
and heels touching the but- 
tocks. Then she should raise 
the pelvis as high as possible, 
and sustain it tor a few mo- 
ments, the shoulders and soles 
4 tting the pelvis slowly descend, 



Fig. 192. 




The Perineal Body destroyed, both Recta] and Vesical 
Walls descend. 



of the feet alone touching the \ 



>eo 



412 



ANTERIOR DISPLACEMENTS OF THE UTERUS. 



she is to repeat this half a dozen times. The movements too for 
strengthening the abdominal muscles mentioned under treatment of 
Prolapse should be practised here, as well as the general exercises indi- 
cated there for the full development of the thoracic and dorsal muscles. 

Pessaries. — What is desired of a pessary in sustaining the ante- 
flexed or anteverted uterus is this: to make gentle pressure on the base 
of the bladder above the cervico-corporeal junction, and as near to the 
fundus as possible, to supplement the vesico-uterine ligaments, and at 
the same time not to injure the vagina by excessive pressure at this 
point. It is by no means easy to make an instrument answer these 
requirements ; it may either keep the uterus in place at the expense 
of a degree of force which will create a solution of continuity in the 
vagina, or it may, when possessed of too little power, allow the fundus 
in spite of it to fall forward. Even with every precaution cases will com- 
monly occur in which the parts will be injured by pressure, and without 
precautions the means is one which is attended by absolute danger. 

The diagnosis having been made, and it having been decided that 
the uterus is movable and not attached by adhesions from a former pel- 
vic peritonitis, and that the displacement results from no condition 
removable only by operation, the treatment should be commenced in 
this way : The intestines should be evacuated by a cathartic, all weight 
removed from the fundus by abdominal and skirt supporters, and the 
patient enjoined to take very moderate exercise and to avoid all violent 
efforts. Every night and morning she should use the hot vaginal douche, 
not only at first, but throughout the duration of treatment, to prevent 
irritation from it. Before the introduction of a pessary the uterus 
should have been several times replaced by conjoined manipulation, and 
held in position for two or three minutes at a time. At the end of 
this period, if the displacement is readily reducible and it requires no 
great force to sustain the uterus, the anteversion pessary represented in 
Fig. 193 may be introduced, and the patient allowed to walk about. 



Fig. 194. 



Fig. 193. 




Thomas's Anteversion Pessary 
as it appears in the Vagina. 




The same Instrument in Position. 



Should it give no pain, she may wear it home, even if going to a dis- 
tance from the practitioner's residence, for she can herself remove it on 
the first menace of injury. In three or four days the instrument 
should be examined. If it have given pain or have left its mark upon 



PESSARIES. 



413 



the vaginal walls, it should be changed at once ; if not, it may he 
left for a week ; then for two weeks ; then for a month ; and afterward 
for a still longer time — two months, for example — without examination. 
The pessary here advised is represented open for introduction and with- 
drawal, and closed as it lies in the vagina. 



Fig. 195. 




Fig. 196. 




Thomas's Anteversion Pes- 
sary as it appears on Re- 
moval. 



Thomas's Elastic Pessary for Anterior Dis- 
placements. 



Fig. 196 represents an elastic pessary for anterior displacements, 
made of spiral wire and strips of whalebone covered with gutta-percha, 



Fig. 197. 




Graily Hewitt's Anteversion Pessary 



by Otto and Sons of this city. The whole pessary is so pliable that it 
can be introduced and withdrawn with perfect ease. 

Cases will occasionally bo met with in which the parts are so sonsi- 



414 ANTERIOR DISPLACEMENTS OF THE UTERUS. 

tive that the hard bulb of these pessaries cannot be borne. Under these 
circumstances they can be with great advantage replaced by soft balls of 
very fine sponge, absorbent cotton, or, better still, prepared lamb's wool, 
until the reposition of the uterus and removal of congestion which is 
thus effected render solid bulbs tolerable. 

Some years ago we were in the habit of using quite extensively 
the pessary of Dr. Graily Hewitt, shown in Fig. 197, as also that of 
Fowler (Fig. 198). But recently we have discarded them almost entirely 
for the instrument devised by Dr. Gehrung of St. Louis, already referred 
to (see Figs. 64 and 6b). Another useful pessary for anteversion 
with moderate prolapsus is that of Hitchcock (Fig. 199), which may be 
used first in its flexible form, and when found to answer the purpose 
replaced by its counterpart in hard rubber. 

Fig. 198. Fig. 199. 



% , 




Fowler's Pessary for Anterior Dis- Hitchcock's Pessary for Ante- 

placements ; also used for Pos- terior Displacements, 

terior Displacements. 

All these pessaries will effect the object of supporting the uterus, 
and to some extent elevating the fundus of that organ in anteversion. 
But in anteflexion none of them will succeed in so far straightening the 
uterus as to entirely efface the angle of flexion. Therefore he who 
expects from these methods extraordinary results will surely be disap- 
pointed. In a certain number of cases failure will attend all means 
thus far devised, not excepting surgical procedures. 

We would especially impress the importance of not relying exclu- 
sively upon any one of these pessaries or internal supporters. Their 
use should be combined with external means calculated to remove pres- 
sure from the fundus. By this combination the happiest results may 
be confidently anticipated from efforts at relief of this often distressing 
accident. 

Before concluding let us recapitulate the most important of the max- 
ims embodied in this chapter : 

1st. Never begin treating a displaced uterus mechanically until 
satisfied that no peri-uterine inflammation exists ; that bad symptoms 
present are due to the displacement ; and that no condition susceptible 
of removal by medical or surgical means requires earlier and more prom- 
inent attention than retention of the uterus in position. 

2d. Before using a pessary act thoroughly on the intestinal canal, 
use hot vaginal injections freely, and replace the uterus repeatedly. 

3d. Do not rely upon vaginal support alone, but aid it by avoidance 
of all pressure from above and by using an abdominal pad. 

4th. Never use a pessary which the patient cannot remove unless 
she keep within reach of your aid ; always examine frequently to see 



PESSARIES. 415 

if injury is being done to the vaginal walls, and never let a patient 
wearing one pass entirely out of observation. 

5th. If no sufficient pouch exist anterior to the cervix for the accom- 
modation of an internal pessary, create one by use of the external bulb 
pessary. 

As already intimated, in many cases of this variety of displacement 
a great deal of relief may be obtained from merely lifting up the dis- 
placed organ in the pelvis, without rectifying the anterior displacement ; 
and for one who is not familiar with the use of anteversion pessaries, or 
has not at his command facilities for procuring good instruments, we 
really think that this, in the commencement of the treatment, if not 
throughout its entire course, is the safer and better plan. This may 
be easily accomplished by means of a flexible ring pessary (Meigs's or 
Peaslee's) and the simultaneous use of the suprapubic pad of wood 
or cork. 

While, technically, it may be more difficult to elevate an anteverted 
or an anteflexed uterus by means of a vaginal support than is the case 
with the retro-displaced organ, owing to the want of a proper base or 
fulcrum from which to exert the upward force, our latest experiences 
have convinced us, fortunately, that uncomplicated anterior displace- 
ments are by far less serious in their consequences, and require mechan- 
ical treatment by no means as often as backward deviations. 

If the uterine congestion so commonly present in these cases has 
been relieved by appropriate measures (hot douches, iodine applications 
to cervix and vaginal vault, glycerin tampons, recumbent posture, saline 
laxatives, etc.) ; if laceration of the cervix has been repaired ; if chronic 
endometritis has been at least improved ; and if congestion or inflam- 
mation of the uterine appendages has been properly treated, — then the 
displacement ceases to give trouble and requires no special treatment. 

In proof of these statements we will merely quote Winckel,.who on 
page 302 of his work (op. cit.) says that he is indebted to B. S. Schultze 
for a change in his views to the effect that since he has recognized that 
" anteversion and anteflexion are most frequently due to extra-uterine 
causes," he has found intra-uterine treatment to be out of place so long 
as these causes are in force. Further, Munde (Mm. Surg., Gynecology, 
p. 394) states that of 407 cases of anterior displacements (295 anteflexion^ 
and 112 anteversions) only 40 (28 flexions, 12 versions) were treated with 
vaginal pessaries and 16 with intra-uterine stems. The reasons why sup- 
porters were thought necessary or beneficial only in 56 cases out of 407 
anterior displacements, as compared with 127 out of 403 cases of retro- 
displacement, is that the symptoms produced by the anterior displace- 
ments were so much less acute than those of the posterior dislocations, 
and consisted chiefly of dysmenorrhoea and sterility : that a supporter 
was indicated only in the aggravated forms ; and the flexions were 
treated and benefited generally by repeated active dilatation by diver- 
gent steel dilators. While Ave have thus materially changed our views 
regarding the relative pathological importance of anterior and posterior 
displacements, we would by no means wish to be understood as aban- 
doning the mechanical supports designed for the former, as our lengthy 
description of them sufficiently shows. 



416 ANTERIOR DISPLACEMENTS OF THE UTERUS. 

As there are men who to-day still doubt the efficacy of support for 
posterior forms of displacement, there must be many more who entirely 
oppose that for anterior. To both classes of objectors we would say, 
with a confidence resulting from a large daily experience, that the hos- 
tility to mechanical support in both varieties of displacement arises 
partly from prejudice, and partly from want of skill on the part of 
the practitioner, who charges to the mechanical process shortcomings 
which really lie at his own door. 

On more than one occasion we have heard the most unmeasured 
denunciations against pessaries upon the part of men who we found had 
been persistently using them upside down. Failing to give relief by 
instruments thus used, the illogical experimenters have been too willing 
to attribute to a method what was really due to an ignorant abuse of it. 

Intra-uterine Stems. — In certain cases of anteflexion, notably those 
requiring the energetic means recently mentioned for their reduction, 
pessaries resting in the vagina fail to accomplish the required purpose, 
and the use of more powerful means of support are resorted to. 

The first to devise an intra-uterine support was Moller, who in 1803 
constructed a stem composed of an elastic catheter with a flexible wire 
stylet. Amussat followed in 1826 with a smooth ivory stem, and Vel- 
peau, Simpson, Valleix, and Kiwisch about 1850 almost simultaneously 
revived the idea. 

The instrument known as the intra-uterine or stem pessary unques- 
tionably counteracts directly and immediately all flexions of the uterus. 
But it was found to cause peritonitis and death in a number of instances, 
and in consequence it was for a time almost entirely abandoned. So 
decidedly did experience appear to weigh against it that it became dif- 
ficult to explain the encomiums once showered upon it by its advocates 
and the remarkable cures reported from its use. Nevertheless, the 
method was never entirely cast aside, for none could hesitate to indorse 
the sentiment expressed by Malgaigne in the discussion upon the sub- 
ject in the Academy of Medicine in Paris in 1852, that "a treatment 
which Amussat, Velpeau, Simpson, Huguier, and Valleix had tried can- 
not, should not, be considered as repugnant to common sense." 

During the last twenty-five years there has been evidenced, however, 
a growing inclination to return to this plan, and the last fifteen have 
brought forth a number of reports favorable to it. 

At a medical convention held in Innsbruck, Germany, in Septem- 
ber, 1869, Spaeth of Vienna and Hugenberger of St. Petersburg 
expressed their belief in the utility of stem pessaries in anteflexions, 
and their comparative safety. More recently, Prof. Schultze of Jena 
advised the use of the intra-uterine stem in certain obstinate cases with 
proper reserve and caution. 

Prof. Olshausen, then of Halle, likewise published his experience 
with the method. Of its character the reader can judge for himself, 
for the professor gives accurate data : Out of 297 cases of versions and 
flexions, 81 were treated by the stem, and 5 were so treated for other 
conditions than displacement. Peri-uterine inflammation resulted in 7 
cases; treatment was stopped on account of hemorrhage or pain 10 
times ; the stem could not be kept in place 3 times. Of 66 cases in 



INTRA- UTERINE STEMS. 417 

which they did well, in 15 the results appeared to be permanent; in 18 
improvement was great and lasted a long time; and in 17 " doubtful 
permanent results were obtained." In 11 sterility was cured. The 
stems were worn for periods varying from a few weeks to twenty-two 
and a half months. 

In order to give the reader an idea of the difference of opinion on 
this question, we will cite a number of names of prominent writers who 
have expressed themselves in more or less decided terms in favor of or 
against the intra-uterine stem : 

For : Amussat, Simpson, Lee, Valleix, Velpeau, Kiwisch, C Mayer, 
Detschy, E. Martin, Veit, Olshausen, Hildebrandt, Haartman, Winckel, 
Schroeder, Lewis, Hennig, Kristeller, Graily Hewitt, Priestly, Savage, 
Greenhalgh, Beatty, Courty, Weber, Grenser, Benicke, Beigel, Ban- 
tock, Chambers, Atthill, Routh, Van de Warker, Eklund, Noeggerath, 
Goodell, Chad wick. 

Against: Depaul, Raciborski, Piorry, Gibert, Cazeaux, Scanzoni, 
Hueber, Hohl, C. Braun, Seyfert, Crede, Freund, Spiegelberg, Habit, 
Retzius, Tilt, Meadows, Oldham, Bennett, West, Duncan, Tait, Skene, 
Byford, Barker, Emmet. 

A Middle Position is occupied by Schultze, Peaslee, Hegar and 
Kaltenbach, G. Braun, A. H. Smith, Chrobak, Byrne, Kinloch, Stud- 
ley, Thomas, Munde. 1 These latter gentlemen do not wholly discard the 
stem, but permit its use in certain cases in which vaginal supporters 
have utterly failed to rectify the distortion, and the gravity of the 
symptoms or the degree of the distortion warrants the use of a remedy 
which is not devoid of danger. The justifiableness of inserting a 
stem simply for the relief of sterility probably due to anteflexion will 
be governed by the same rules as those for other no less dangerous 
measures — the dilatation of the uterine canal by tents, dilators, and the 
knife. It is allowable to let the patient run a certain amount of risk 
in order to gratify her desire for maternity, but she should be made 
acquainted with the risks, and from her should come the decision. 

Precautions and Dangers. — In no case where there is evidence to 
be felt of a preceding pelvic inflammation should an intra-uterine stem 
be used. The great danger is in the production of pelvic peritonitis 
or of acute inflammation of the tubes and ovaries. To avoid this as 
much as possible we always employ the following precautions : After 
thoroughly disinfecting the vagina by a 1 to 10,000 sublimate douche, 
we give the patient an anaesthetic (usually), through Sims's speculum thor- 
oughly dilate the uterine canal with Palmer's dilator, if necessary pre- 
viously dividing the external and internal orifices with Studley's probe- 
pointed knife (Fig. 204) or a blunt straight bistoury, and then, again dis- 
infecting the vaginal and uterine canals, gently and carefully insert the 
stem, never using one longer than two and a quarter inches, so as not to 
touch the fundus. We now either pack the vagina with iodoform gauze 
if there appears danger of bleeding, or usually introduce a pessary (Fig. 
201) devised by Dr. Thomas, which keeps the stem in place. The 
stem we employ is either a straight one of hard rubber (see Fig. 200) 
or a slightly curved one of glass. The patient is at once put to bed. 

1 Mun<U\ Minor Surg. } Oi/n., 1885, p. 401. 



418 ANTERIOR DISPLACEMENTS OF THE UTERUS. 

an ice-bag placed over her hypogastriuni for twenty-four Hours, and 
she is not allowed to rise for a week or until all abdominal pain has 
ceased. Any severe or continuous pain in the hypogastric region calls 
for the immediate withdrawal of the stem, which can be done by the 

Fig. 200. 





Intra-uterine Stem. Cup Pessary for holding Stem in Place. 

patient herself by simply pulling out the pessary, when the stem will 
follow of itself. When anteversion is also present the vaginal pessary 
is not needed, as the stem is retained by pressure against the posterior 
vaginal wall. 

We usually remove the stem and pessary immediately before and 
reintroduce them after each menstrual period, in order to facilitate the 
escape of the discharge ; but this is not absolutely necessary. .Patients 
have even been known to conceive with the stem in sM; Winckel, Ols- 
hausen, Goodell, and others report such cases. In order to permanently 
straighten an anteflexed uterus, the stem must be worn for months, and 
even then, unless speedy conception occurs, a cure may not be obtained. 
Still, d} T smenorrhoea has usually been entirely relieved by this treatment 
in our hands. 

Under the above precautions a serious accident now rarely follows 
this treatment. We ourselves have met with but few accidents and no 
deaths. 

But in a certain number of cases even the intra-uterine stem fails. 
Then the gynecological surgeon, following the example of the general 
surgeon, gives up striving after an end unattainable by minor means, 
and resorts to the knife for relief. 

Should the patient not tolerate the intra-uterine pessary with com- 
fort, should the flexion not yield to the treatment by it, or should the 
practitioner prefer to adopt operative procedures, an operation devised 
by Sims is at his disposal — not intended to cure the displacement, but 
to remedy its resulting cervical obstruction, leaving the disorder of 
position unchanged. 

Operation for Irreducible Cervical, Corporeal, or Cervico-corporeal 
Flexion. — If a piece of stiff tubing be bent, the calibre of its canal 
will be obliterated at the point of flexion in proportion to the acute- 
ness of the angle created. In the same manner is the uterine canal 
affected by the lesion under consideration. The obstruction created 
in this way prevents the free escape of menstrual blood, which distends 
the cavitv of the uterus and forms clots within it, and these at each 



OPERATION FOR ANTEFLEXION. 



AY.) 



Fig. 202. 



menstrual period are expelled by uterine tenesmus. In consequence of 
this, inflammation of the mucous lining of the uterus arises that in 
time may produce areolar hyperplasia, which favors further displace- 
ment by the increase of uterine weight attending it. The effort 
required for expelling clotted menstrual blood creates painful menstrua- 
tion, and the same obstruction which retards egress of fluids interferes 
with ingress and prevents conception. 

In spite of the denial of prominent authorities that a flexed uterine 
canal causes this form of dysmenorrhea, known as obstructive, we still 
are ourselves compelled to retain the theory here advanced, both because 
it seems anatomically correct and logical, and because we know of no 
better explanation of the facts. 

Having been forced to accept the displacement as an irremediable 
evil, we now endeavor to strike at one of the sources of the pathological 
series which results from it by overcoming obstruction at the point of 
flexure ; in other words, by substituting a straight for a crooked canal. 
This can be accomplished by cutting 
through one wall of the cervix. Having 
thus overcome cervical obstruction and 
consequent accumulation of fluids in 
utero, do Ave at the same time remove 
the tendency to mechanical congestion of 
the body of the uterus ? Not entirely, 
but if we secure the results of cervical 
section, as we may ordinarily do by 
subsequent use of the intra-uterine stem, 
we accomplish to a certain extent both 
results. 

If the posterior uterine wall, bent 
forward as shown by the line e b, Fig. 
202, in a case of anteflexion, be cut 
toward the vaginal junction, so that a 
probe will pass into the uterus in the di- 
rection of the line a d, the obstruction 
resulting from the existence of an angle 
will be removed, and thus fluids will 
have free entrance and exit, for instead 
of turning the angle at b and escaping 
at (\ they will at once escape at b. 

The operation which accomplishes 
this result is an exceedingly simple one, 

and is thus performed : The patient being placed in position and Sims's 
speculum introduced, the cervix is seized and drawn down by a tenacu- 
lum. Then by a long slender knife — that of Sims's is the best — an 
incision is made as far as can be conveniently done without involving 
the vaginal junction, which will probably be above the point b in Fig. 
202. The blade of Sims's knife, represented in Fig. 203, is now intro- 
duced through the os internum, and the tissues are cut so as to lav open 
the posterior wall of the cervix. A little shoulder will, as Dr. Emmet 
has pointed out, be generally found to exist on the anterior wall of the 




Schematic Diagram, showing the Crea- 
tion of New Uterine Axis: a b repre- 
sents the axis of the body ; b c rep- 
resents the axis of the neck : b d 
represents the axis created by incis- 
ion. 



420 ANTERIOR DISPLACEMENTS OF THE UTERUS. 

canal, just at the angle made by flexure of this wall. Toward this 
the blade of the knife should now be turned, and it should be cut 
through. 

Fig. 203. 




Sims's Adjustable Uterine Knife. 



In this operation the knife alone should be used. None of the 
uterotomes are at all appropriate. Just after the operation the glass or 
hard-rubber stem shown in Fig. 200 should be introduced, so as to occu- 
py the whole cervix from above the os internum to os externum. Under 



Fig. '204. 




Studley's Probe-pointed Knife, for division of internal os. 

this a firm tampon of iodoform gauze should be placed, which may be left 
in situ for five or six days or until saturated, when it should be replaced 
by another similar tampon if there is the least sign of hemorrhage. If 
not, the stem may be kept in place by the pessary shown in Fig. 201, 
daily irrigation with tepid carbolized (2 per cent.) water being used. 
The patient should be kept in bed at least a week. The same precau- 
tions as detailed for the insertion of a stem without this deep incision 
apply here. Particular attention should be paid to tightly packing the 
vagina : we ourselves have had one quite serious case of secondary 
hemorrhage occurring within three hours after the operation, which 
warned us not to be careless in this respect. The stem and pessary 
should be worn, if no evil symptoms develop, for two or three months. 
Then, after cicatrization has fully occurred, they may be removed, with 
a reasonable hope that the canal will remain pervious. 

Success in this operation depends less on its method of performance 
than on the persistent wearing of the stem until cicatrization has been 
fully accomplished. 

Should an error be made as to the etiology of the displacement or 
the recognition of its complications, and this apparently trifling opera- 
tion be performed during the existence of peri-uterine cellulitis or peri- 
tonitis, the gravest results may follow and the sufferings of the patient 
be greatly aggravated. Indeed, had all the fatal cases which have 
occurred in consequence of this operation been published to the profes- 
sion, as they should have been, the list would, we think, be a startling 
one. We ourselves know of several, and have heard rumors of many 
others. It may be asked why this operation upon the part of the uterus, 
which does not ordinarily resent surgical interference, should so often 



OPERATION FOR ANTEFLEXION. 421 

be followed by dangerous consequences. Our conviction is that the 
operation per se is not attended by great danger. It is the perform- 
ance of it when pelvic peritonitis exists in chronic form that has caused 
it to produce such bad results. Even a minor operation, performed in 
the face of a condition which should interdict the use of the uterine 
probe, may set up a train of symptoms which may lead to a fatal issue. 

After those procedures for the cure of anteflexion which has for a 
long time been irreducible, and was very probably congenital, concep- 
tion is by no means common. Operations for this condition often effect 
relief of menstrual and amelioration of circulatory disorders ; and they 
may even cure sterility, but he who practises them should beware how 
he makes promises to this effect. 

It is very evident that at present a formidable wave of professional 
opinion is steadily advancing in opposition to this operation. Some of 
the very men who took exaggerated positions in reference to its value 
ten years ago are now emphatic in its denunciation. It is the old story 
of the swing of the pendulum. The operation should hold to-day just 
the position to which it was entitled ten years age. Its merits are 
unquestionable ; its place cannot in the interests of gynecology be left 
vacant. But as it did not deserve the encomiums of a former time, so 
it does not merit the depreciation which is aimed at it to-day. 

One of its advantages has been, we think, lost sight of. Many cases 
of obstructive dysmenorrhoea, sterility, and inefficient menstruation, for 
which resort has been had to it with good effect, are due to an undevel- 
oped state of the cervix, which, compared with the body of the uterus, 
is disproportionately small. Section, followed by the use of the intra- 
uterine plug for two or three months, will often improve the nutrition 
of the cervix and result in its increased development, as well as stim- 
ulate circulation in the body of the uterus and promote a free menstrual 
flow. 

New operations, more or less ingenious and more or less permanent, 
are constantly being devised for ailments of different portions of the 
body ; and the uterus is no exception to this statement. So far, none 
has been suggested which would straighten a sharply anteflexed uterus. 
The latest candidate for professional favor is one by Dr. E. C. Dudley 
of Chicago, which he demonstrated before the New York Obstetrical 
Society in Nov., 1890, and at the New York Woman's Hospital at about 
the same time. Theoretically and at the time of the operation it cer- 
tainly appeared to do what it claimed. A full description of it will be 
found in the American Journal of Obstetrics for January, 1891. 



422 



POSTERIOR DISPLACEMENTS OF THE UTERUS. 



CHAPTER XXX. 

POSTERIOR DISPLACEMENTS OF THE UTERUS. 

Retroversion and Retroflexion. 

Definition and Frequency. — Retroversion consists in a posterior 
inclination of the uterus, so that the fundus approaches the sacrum and 
the cervix advances toward the symphysis pubis. As an idiopathic 
primary lesion it is not common, but it is frequently symptomatic of 
neoplasms, areolar hyperplasia, or other states which increase the weight 
of the uterus. 

Fig. 205. 




Retroversion of the Uterus. 

Retroflexion is said to exist when the body of the uterus is bent 
toward the sacrum, so as to create an angle on the posterior wall. 

Predisposing Causes. — The predisposing causes of posterior dis- 
placements are parturition, general muscular debility, and habits of 
indolence and inactivity. 

Exciting Causes. — These may be classified under four heads : 



CAUSES OF RETRO VERS I ON AND RETROFLEXION. 423 
Fig. 206. 




Retroflexion of the Uterus. 

Influences increasing uterine weight : 
Fibroids ; 
Subinvolution ; 
Areolar hyperplasia ; 
Pregnancy ; 
Congestion. 

Influences dragging the uterus out of place : 
Adhesions from pelvic peritonitis ; 
Prolapsus of posterior vaginal wall. 

Influences forcibly displacing the uterus by direct pressure : 
Severe succussion by blows or falls ; 
Muscular efforts ; 
Distended bladder ; 
Tumors ; 

Tight bandaging after parturition ; 
Tight and heavy clothing. 

Influences weakeniyig uterine supports : 

Parturition ; 

Destruction of power of perineum ; 

Prolapse of vagina. 
Of all these causes, the two most frequent are decidedly 
of the vagina from subinvolution or ruptured perineum ; and 
hyperplasia, commonly the advanced stage of subinvolution of 



prolapse 
areolar 

the ute- 



424 POSTERIOR DISPLACEMENTS OF THE UTERUS. 

rus. All the others mentioned are sometimes met with, but, compared 
with these, they are insignificant as causes. 

As might be presumed from the natural obliquity of the uterus, ante- 
rior displacements not unfrequently occur as idiopathic lesions resulting 
from pressure of superincumbent viscera forced down upon the fundus 
by tight clothing or muscular efforts. Retroversion occurs in this way 
less frequently. It generally depends upon some pathological state in 
the uterus or its appendages. The third class of causes mentioned as 
displacing the organ by direct pressure may act through violent succus- 
sion, and induce sudden displacement with symptoms of most urgent 
character. Prolonged pressure from a distended bladder or from a 
tumor anterior to or above the uterus may likewise induce gradual dis- 
placement. A little reflection will explain how the management of 
parturient women, by British and American practitioners at least, favors 
the occurrence of the accident. In the first place, it must be remem- 
bered that pregnancy combines in itself two of the influences which are 
productive of this condition — increase of uterine weight and relaxation 
of supports. It is no exaggeration to assert that the usual plan of man- 
agement after parturition supplies one of the others which are mentioned 
above. The woman lying almost constantly upon her back, the heavy 
fundus naturally tends to fall backward into the hollow of the sacrum. 
Many nurses insist upon this position, and often for days refuse the 
patient the privilege of lying upon the side. But this is not all : many 
a nurse's reputation among ladies rests upon her capacity for "preserv- 
ing the figure" by tight bandaging. A powerful woman will often 
expend her whole force in making the bandage as tight as possible to 
accomplish this purpose. No one who has watched the process can 
doubt its influence in displacing the uterus by direct pressure. There is 
no practice connected with the lying-in room to which so much of almost 
superstition attaches as to the use of the obstetric bandage for preser- 
vation of the figure and prevention of hemorrhage. This is a repeti- 
tion of what we have elsewhere stated, but the importance of the sub- 
ject in our mind must be our excuse for dwelling upon it here. 

If involution have gone on tardily and imperfectly, the woman is 
still more prone to have the uterus forced backward. The round liga- 
ments, which are composed of muscular structure similar to that of the 
uterus, are important agents in preventing this. It is highly probable 
that an arrest of retrograde metamorphosis affecting the uterus may like- 
wise affect them, and leave them longer and less powerful than natural. 
"Hypertrophy of the two (round) ligaments," says Scanzoni, 1 "con- 
stantly accompanies a natural pregnancy ; while, as we have ourselves 
had an opportunity to determine, in the case of a bicorned uterus, 
biparted or bilocular, the ligament corresponding to the side on which 

was the pregnancy was alone hypertrophied We remember many 

cases of women who have died after metritis or puerperal peritonitis, 
with whom one or both of the round ligaments were notably hypertro- 
phied, and presented a lively red color with a serous infiltration." 

Not only as a result of pregnancy do these ligaments develop a con- 
dition which renders them prone to yield to traction from an enlarged 

1 Scanzoni, op. cit., p. 358. 



VARIETIES OF RETROVERSION— PHYSICAL SIGNS. 



425 





Fie 


r. 207. 


. 






:% 




1m-1_ 



The Degrees of Retroversion. 



Through so many avenues 



uterus — Boivin and Duges have observed hypertrophy in them, with 
dilatation of their vessels from chronic engorgement, fibroids, and even 
from ovarian tumors. 

Varieties of Retroversion. — Retroversion may exist in slight degree, 
the uterine axis inclining so as to make with that of the superior strait 
an angle of 45° ; or it may incline to 
90°, thus lying across the pelvis; or the 
cervix may be thrown up and the fundus 
descend, so as to form an angle of 135°. 
These varieties constitute the first, sec- 
ond, and third degrees of retroversion. 
Retroflexion also has been divided 
into varieties dependent upon the degree 
of intensity, but these are so entirely 
arbitrary that they may as well be 
ignored. 

Symptoms. — Posterior displacements 
produce annoying symptoms by creating 
congestion of the uterine body, obstruct- 
ing the cervical canal, and causing pres- 
sure on the rectum, congestion of the 
ovaries, and reflex nervous manifestations, 
of approach, it may well be supposed that the symptoms are numerous. 
They are usually as follows : 

Severe backache ; 

Weight in rectum with tenesmus ; 

Nervous disturbances ; 

Difficult locomotion ; 

Menorrhagia ; 

Tendency to abortion ; 

Pain on sexual intercourse ; 

Pelvic and crural neuralgia ; 

Uterine colic or tenesmus ; 

Sterility. 
Many of these symptoms produce epiphenomena of their own, and thus 
increase a list which is already long. 

Physical Signs. — The diagnosis is made by the following means : 

Vaginal touch ; 

Conjoined manipulation ; 

Rectal touch ; 

The uterine probe. 
The patient lying on the back, the index finger is introduced to the 
cervix, which is found in its normal place. It is then swept over the 
base of the bladder, where nothing abnormal is observed. Then it is 
passed into the fornix vaginae, and here a round tumor continuous with 
the ridge of the cervix is discovered. The disengaged hand is then 
placed on the abdomen, and made to approximate the finger in the 
vagina, so as to grasp the body of the uterus. If the abdominal walls 
be lax, this will yield good results, but not otherwise. The finger 
should now be carried into the rectum, in order to study further the 



426 POSTERIOR DISPLACEMENTS OF THE UTERUS. 

character of the tumor pressing upon this canal. The sound may now 
be inserted, or, the patient being placed upon her side and the speculum 
introduced, the uterine probe, which has been curved in accordance 
with the direction impressed on the mind by the sense of touch, is 
gently passed into the uterine cavity to the fundus, which completes 
the diagnosis. 

Differentiation. — This displacement may be confounded with fecal 
impaction, fibrous tumors, cellulitic or peritonitic exudation, extra-uterine 
gestation, a prolapsed and enlarged ovary, and prolapsed kidney. 
The careful practice of the four diagnostic methods mentioned will 
remove all doubts. 

In certain very rare cases the kidney has been known to prolapse 
into the pelvis behind Douglas's cul-de-sac and produce the most 
anomalous symptoms. 

[In a case of my own, in which a very obscure tumor existed posterior 
to the uterus, this diagnosis was made by Dr. Noeggerath in consultation. 
In accordance with his advice I placed the patient in the knee-chest position, 
and applied a good deal of upward pressure, when the tumor suddenly 
escaped into the abdomen. Support was given by a bulb pessary, and for a 
time my patient was relieved, but upon her return to her home in Virginia 
a complete relapse occurred. Dr. Noeggerath tells me that he has met 
with but one other such case. Of course the correctness of the diagnosis is 
doubtful. I am inclined to admit it from the peculiar symptoms exhibited, 
and by the fact that post-mortem examination proves that such a prolapse 
of a floating kidney sometimes occurs. — T. Gr. T.] 

The following account of such a case may be found in Braithwaite's 

Retrospect : 

" Examining the body of a man who had died of phthisis, aged thirty- 
five, Dr. Isaacs found the left kidney located in the pelvis, its upper end 
being in contact with the bifurcation of the aorta, and its lower touching 
the posterior surface of the bladder, and lying on the fifth lumbar vertebra and 
first, second, and third pieces of the sacrum. Its right edge was in contact 
with the rectum, and the left with the iliac portion of the brim of the pel- 
vis. There were three renal arteries — one coming from the aorta, and two 
others from the right common iliac. The kidney was of the ordinary size, 
but the suprarenal capsule was twice its natural size and of the shape of a 
fig-leaf, and it occupied its normal position in the lumbar region." 

[I removed a displaced kidney three years ago by laparotomy, hav- 
ing mistaken it for an adherent and enlarged ovary and tube, and not 
discovering the error until the enucleated organ was brought out of 
the abdominal cavity. The woman recovered. Further reference is 
made to the case in the chapter on Salpingo-obphoritis. — P. F. M.] 

Consequences of Posterior Displacements. — The post-uterine peri- 
toneal space being much more extensive than the anterior, these proceed 
to a more aggravated degree than anterior displacements. The body 
sometimes descends to the upper extremity of the vagina, and instances 
are recorded by Rokitansky and Scott in which it penetrated the walls 
of the rectum and vagina and forced itself into these canals. This, of 



FBEQ UENCY—TREA TMENT. 427 

course, is a very rare occurrence, but it is worthy of mention as show- 
ing how great is the pressure which a retroflexed uterus may exert. 
The ordinary consequences of the affection are — 
Dysmenorrhea ; 
Endometritis ; 
Sterility ; 
Areolar hyperplasia. 

Should pregnancy occur during the existence of this deviation, or 
retroflexion complicate pregnancy, and the fundus be incarcerated below 
the promontory of the sacrum, abortion will result. This cause of that 
accident is so very common that it should be suspected and examined 
for in every case of habitual abortion. Sterility is not so common a 
result of retro-positions as of anterior distortions. Winckel gives the 
following figures : In ante-deviations 28 per cent, were sterile ; the 
proportion of births was 2.6 per cent., and abortions occurred in 22 
per cent. In retro-positions, sterility only in 10 per cent. ; 3.7 to 4 per 
cent, of births ; and only 9.4 per cent, of abortions. 

Frequency. — As a rule, retro-positions are more frequent in women 
who have had children than in virgins or nulliparous women. This, it 
will be remembered, is the reverse from anterior distortions and dis- 
placements. 

Winckel 1 found in over 600 cadavers 4.3 per cent, of retroversions 
and 5.7 per cent, of retroflexions, or exactly 10 per cent, of all retro- 
positions. Schultze found an average of 10 per cent, of retroversions 
and 17.2 of retroflexions in his own practice, or more than double the 
percentage of Winckel. But Schultze's percentage is taken from patients 
who consulted him for some form or other of pelvic disease, and there- 
fore more correctly expresses the proportion of retro-displacements in 
gynecological cases. 

Munde 2 found 403 retro-positions (348 retroversions and 55 retro- 
flexions) among 2500 patients with uterine diseases, or about 16 per 
cent. Winckel, at another point, gives 19 per cent, of 3061, and later 
16 per cent, of 5665 patients, as the proportion in his own practice. 
Therefore, from 16 to 20 per cent, may be fairly assumed as about the 
correct proportion of retro-displacements among gynecological cases. 

Of all posterior displacements, only about 10 per cent, occur in vir- 
gins and nulliparae (Winckel). 

Prognosis. — There are three conditions which render the prognosis 
of this displacement unfavorable : where the uterus is bound down by 
strong adhesions ; where the organ contains in its parenchyma a fibrous 
tumor; and where the vagina is attached to the cervix so near the 
external os that no pessary can rest posterior to the cervix to sustain 
the uterus after it is replaced. This form of utero-vaginal junction is 
important as giving ground for a very grave prognosis as to the euro of 
all anterior and posterior displacements. 

Treatment. — The first indication is to restore the uterus to its place, 
the second to prevent its again becoming displaced. 

Methods of Reduction. — In an ordinary case, in which the uterus 
is not firmly held in retroversion by the surrounding parts, the patient 
1 Lor. eit. - /.,),'. cit. 



428 POSTERIOR DISPLACEMENTS OF THE UTERUS. 

should be placed on the left side as for an ordinary examination with 
Sims\s speculum. The operator, then lubricating the index and middle 
finger of the right hand, introduces them, he standing at the patient's 
back and facing her head, and the palmar surfaces of the fingers being 
directed to the rectum. The body of the uterus is then lifted upon the 
tips of the fingers until it becomes erect ; then their dorsal surfaces, 
which will really be the backs of the nails, are made to push the organ 
over into normal position. As the uterus becomes elevated the middle 
finger is still kept in the post-uterine space to maintain what is gained, 
while the index finger is carried in front of the cervix, and this part is 
by pressure forced back toward the sacrum. The middle finger is now 
likewise placed in front of the cervix, and by both fingers this part is 
forced toward the sacrum, and kept there for a short time. This 
method of replacing a uterus which has fallen backward is superior to 
any other that we know of. We would urge a trial of it exactly as here 
described, and will answer for its efficiency. 

But sometimes the uterus is irreducible by any but the most power- 
ful methods. In such a case, the bladder and rectum having been 
evacuated and the clothing loosened, the patient is made to kneel upon 
a hard surface, and to place the sternum as closely as possible in con- 
tact with the plane which supports her. The practitioner, then lubricating 
two fingers of the right hand, carries them into the vagina and against 
the fundus. He then directs the patient to fill the chest with air and 
expel it completely. As she does so he forcibly elevates the fundus 
and restores it to its place. Should this plan fail, the buttocks should 
be still more elevated by placing cushions under the knees, and the 
attempt repeated with two fingers in the rectum instead of in the vagina. 

Should these powerful and usually efficient methods fail, we would 
strongly urge against efforts being made by introduction into the uterus 
of instruments for restitution. If they exert less force, they will not 
be effectual ; if more, they may penetrate the uterus and create perito- 
nitis. Besides, in a case resisting the plan detailed there will prob- 
ably be found to be adhesions as the source of the difficulty. Under 
these circumstances Kuechenmeister 1 has, from extended experience, 
advised the introduction of the colpeurynter filled with water every day 
for as long a time as the patient can bear it. Steady hydrostatic pres- 
sure often in this way accomplishes safely what sudden force would do 
with danger to the patient. 

In cases requiring the application of much less force Sims's repositor 
is an excellent instrument for the purpose, and should be employed. 
This instrument, which is represented by Fig. 208, consists of a short 
metal sound terminating in a ball. The ball is clasped by a straight 
shaft, moves upon a pivot running through its centre, and is perforated 
by seven holes. Through the shaft runs a rod which is projected by a 
concealed spring that is governed by the finger passed through the 
ring. The ball can be made to revolve, so that the sound describes a 
half circle, by withdrawing the stop-rod which runs through the shaft 
and depressing the instrument. 

In many instances reposition is perfectly practicable by conjoined 

1 Am. Journ. Med. Sci., July, 1870, p. 275. 



METHODS OF REDUCTION. 



420 



manipulation or rectal taxis, or by means of a sponge fixed in a sponge- 
holder and pressed into the fornix vaginae. In replacing a uterus in 
this or any other malposition the operator should never forget that 

Fig. 208. 




Sims's Uterine Repositor. 

inflammatory action may have caused an effusion of lymph around it 
which resists its removal, and that if these adhesions be violently rup- 
tured peritonitis may result. 

As early as 1820, Von Ritgen of Giessen recommended the knee- 
chest position for the automatic replacement of the retroflexed womb, 
and since his time the method has been often resorted to as an adjuvant 
to replacement. To Dr. H. F. Campbell, however, belongs the credit 

Fig. 209. 




Fig. 210. 




The Genu-pectora] Position, showing its Action in Retroversion. 



of systematizing it as a method of "pneumatic self-replacement," and 

putting it at the disposal of the gynecologist for daily use. lt ("amp- 



430 POSTERIOR DISPLACEMENTS OF THE UTERUS, 

bell's method" never does harm, generally effects great good as an 
adjuvant to other treatment, and in rare cases proves in itself sufficient 
for complete relief. It consists simply in the reversal of gravity by 
placing the patient in the attitude represented in Figs. 209 and 210, an 
examination of which will at once show the action of the method upon 
intestines and uterus. Dr. Campbell likewise directs that a small glass 
tube, about as large as the largest sized test-tube, should be introduced 
into the vagina by the patient while in the " genu-pectoral " position, 
to secure the admission of air and its action as a repositor. 

During the treatment of all uterine displacements, except inversion 
and irreducible flexion, the patient may with advantage be directed to 
practise this automatic method of replacement for live or ten minutes 
upon retiring at night and upon rising in the morning. If a pessary 
be worn, it will be by this plan relieved of much of the pressure which 
it bears, congestion of the pelvic viscera will be lessened, and the 
organs of the abdomen, being displaced upward, will not immediately 
descend and depress those of the pelvis. 

After replacement has been effected by any one of these methods 
the sound may be employed to make sure of its thoroughness and to 
increase it. It should never be used for this purpose before manual 
replacement, and even after it, it should be employed very cautiously 
and by the following steps : 

1st. It should be introduced, but slightly bent, to the fundus. 

2d. Holding the handle in his left hand, the operator should place 
the tips of the fingers of the right hand upon the shaft and carry it 
toward the perineum as far as possible. 

3d. The uterus being now, to a certain degree, straightened and ele- 
vated, the sound should be rotated so as to throw the fundus forward, 
and the handle of the instrument held in one hand be carried toward 
the patient's back, so as to advance the tip as far as possible toward the 
abdominal walls. 

Reading a procedure thus described often leaves the impression that 
it is a complicated one, and perhaps that the directions given are unim- 
portant. Let one who has habitually used the sound simply as a rotator 
fairly try this more delicate and rational employment of it, and we are sure 
that he will adhere to it, even although prejudiced against it originally. 
.Sims's repositor likewise answers a good purpose in rendering replace- 
ment complete after partial replacement by the fingers. 

Means for Retaining the Uterus in Position. — Having replaced the 
uterus, the question which arises is, How are we to prevent the recur- 
rence of displacement at a very early period ? Careful attention should 
immediately be paid to the following points : 1, all pressure from above 
should be removed by the use of the skirt supporter, the abdominal 
supporter, and avoidance of injurious muscular efforts; 2, increased 
weight of the uterus should be diminished by the adoption of means 
already pointed out for the fulfilment of this indication ; 3, feebleness 
of the uterine supports should be remedied by exercises calculated to 
develop the retentive powers of the abdomen and by general and local 
tonics ; and 4, all traction upon the uterus should be removed by perin- 
eorrhaphy or this combined with colporrhaphy. The fulfilment of 



METHODS OF RETENTION— TAMPONS. 431 



m 



one or of all these indications may at once bring relief to a case 
which less radical and more desultory efforts might be indefinitely 
prolonged with only partial benefit. As the means for fulfilling these 
indications have been already fully pointed out, we shall not repeat 
them here. 

All causes which originally excited and still perpetuate the accident 
having been as far as possible combated, the chief and most immediate 
indications are clearly to replace the displaced uterine body and to keep 
it in position. 

For the purpose of fully exhibiting the method of treating a chronic 
case of this disorder, we will suppose that we are dealing with one of 
rebellious character, in which there is considerable tenderness about the 
uterus, so that it will not tolerate the pressure of a pessary sufficiently 
powerful to keep it in position. The bowels should be evacuated ; the 
vagina thoroughly syringed with hot water night and morning ; all 
weight taken from the abdomen by a skirt supporter, an abdominal 
supporter, and avoidance of all muscular efforts ; and the uterus be 
replaced and held in the condition of complete anteversion for two or 
three minutes once in every forty-eight hours, for a week or more. 
As an additional preparation for the permanent support of the displaced 
organ a tampon of carbolized cotton should be applied in the following 
way : The uterus being pushed into a state of complete anteversion, a 
roll of cotton about the size of a small hen's egg, or an egg-sponge 
moistened with boro-glyceride or carbolized glycerin, should be care- 
fully pushed as far as it will go into the fornix vaginae. Then a large 
roll of cotton should be placed below the cervix and a little anterior to 
it (not behind it, as the first one was), but so arranged as to lift this part 
up into the hollow of the sacrum against the roll, which has now become 
invisible, in the fornix vaginae. The subcervical tampon not only 
pushes back the cervix which was before its introduction near the sym- 
physis pubis, but it still further elevates the supracervical roll, which 
thus pushes the fundus farther and farther upward until it topples over 
forward by its own weight, uninterfered with as it is by pressure from 
above and aided by the abdominal decubitus which should be observed 
by the patient. The accompanying diagram will explain the action of 
these two portions of the tampon ivheM prop- 
erly applied. If, instead of being thus 
inserted, the ordinary tampon be employed 
and the lower portion of the vagina be 
filled, nothing is accomplished but elevation 
of the retroverted organ. What we desire 
to produce is anteversion. After the intro- 
duction of the cervical pad, as shown in the 
figure, the vagina is filled with cotton to keep 
this in place, as well as to elevate the whole 
uterus and bring gravitation to our aid in 
throwing the body forward. We do not look 
upon the abdominal decubitus as a valuable 
resource in the treatment of retroversion. Retention of previously Retro 
but merely as an adjuvant to other means \?*% SpoiS N ° rmal **? 




432 POSTERIOR DISPLACEMENTS OF THE UTERUS. 

which directly straighten the axis of the uterus. Lift the retroverted 
organ, and it has a certain degree of efficacy as an adjuvant which it 
does not possess while the displacement is in existence. The tampon 
may be retained for forty-eight hours without inconvenience if the 
material of which it is composed be properly prepared by means of 
antiseptic drugs. 

Cotton impregnated with antiseptic and alterative substances, such 
as borax, carbolic and salicylic acids, zinc, copper, alum, iron, etc., 
may now readily be obtained from druggists, so that the physician 
need not charge himself with its preparation. 

Prepared sheep's wool, being more elastic and less liable to cake, 
forms a desirable substitute for absorbent cotton. 

During the use of this means the patient may go about and attend 
to her usual avocations, although sometimes it is better to confine her 
to bed. 

We sometimes effect the same result by introducing a Hoffman's or 
Hurd's inflated rubber pessary, and then placing under this a tampon 
which will press it firmly up against the displaced fundus. 

Should the residence of the patient be out of the city or her pecu- 
niary condition render it impossible for her to be treated as here 
advised, the plan may be imitated by one which is very effectual, and 
much less troublesome to patient and phy- 
sician. The uterus being thrown into ante- 
version by the repositor, or two fingers intro- 
duced into the fornix while the patient is 
in the left lateral position, a sponge pessary, 
which consists in the attachment of a soft egg- 
sponge, instead of a bulb, to the stem of 
Cutter's pessary (Fig. 220), should be left in 
Hoffman's inflated. Soft-rub- position. The sponge fits in the vaginal cul- 
de-sac, is steadily pushed upward against the 
uterus by the elastic dorsal strap, and forcibly but gently keeps the 
organ in normal position. For such cases as those just indicated, and 
for others in which the retroversion is so obstinate that it recurs in 
spite of a pessary passed entirely into the vagina, this constitutes a 
means of such great value that we urge its trial in all difficult cases. 
By it we have controlled many cases which had resisted all other plans 
of mechanical treatment, and feel assured that it will not fail to pro- 
duce in the hands of others as good results as it has yielded us. Of 
course it is only a temporary and preparatory means, for sponge is at 
all times an objectionable substance to leave in the vagina. It should 
in this case be removed, washed, and replaced by the patient once in 
every twelve hours. 

After the methods thus far described have been pursued for a 
month or two, even the worst cases will generally tolerate a well- 
adjusted permanent pessary; but where this tolerance is not estab- 
lished, the medicated tampon or sponge pessary should be continued 
until it becomes so. 

Better than the sponge pessary, if procurable, is a spring pessary 
covered with soft rubber, the post-cervical part of which is inflated 




METHODS OF RETENTION— PESSARIES. A?j?> 

and represents an air-cushion. It, like all other soft-rubber pessaries, 
should be removed and cleansed about once a week to prevent its 
becoming offensive. 

One important point in connection with this method of replacing 
the uterus is this. The round ligaments are attached to the horns of 
the organ and at the vulva. If the retroverted or retroflexed uterus 
be left in malposition and simply pushed up, the ligaments will inevit- 
ably increase and ensure the continuance of the displacement. If, on 
the other hand, the body be thrown forward and kept in anterior posi- 
tion until the organ be lifted, the round ligaments, becoming tense, 
tend to act remedially on posterior deviations. A little thought will 
convince the reader of the truth of this statement. It is upon this 
action of the round ligaments that we in part depend for the benefit 
of the plan which we are describing. 

It may be asked whether we propose to treat all cases of retrover- 
sion in this manner in the beginning. By no means so. We prefaced 
these remarks upon preparatory treatment by stating that we supposed 
the practitioner to be dealing with an aggravated case and one intole- 
rant of support. Most cases will at once admit of the use of a retro- 
version pessary, and require no preparatory treatment. There are, 
however, many others which do require it, and in which immediate 
resort to artificial support proves injudicious and even dangerous. 
Some may suppose that a great deal of time must be consumed by this 
preparatory treatment which is not absolutely necessary for the relief 
of the case. If preparatory treatment be not necessary, it should not 
be resorted to ; if it be necessary, time will be gained and not lost by 
its adoption. At least let us urge this advice : when the most care- 
fully adjusted pessaries create discomfort, let a month be devoted to 
the preparatory treatment which we have described, and at its end let 
pessaries be again tried. Many cases will then be found to yield to 
mechanical treatment which were rebellious to it before, and more cer- 
tainly so if the means recommended for removing pressure upon the 
fundus from above be faithfully put in practice. Some of the most 
gratifying results of gynecology will be found to arise from a cautious, 
patient, and philosophical treatment of these cases. But let no one 
suppose that a careless fulfilment of the directions given is likely to 
perform all this. If the plan which we 
are urging be used unintelligently and FlG - 213 - 

roughly, it will do harm and not good, 
and result in annoyance and not comfort 
to the patient. 

It has now been decided, we will sup- 
pose, to try the effects of a retroversion 
pessary. Which of the many varieties at 
our command shall be selected ? The 
oldest and most generally known of 
these instruments, Hodges pessary, still 

holds its place in professional esteem, and 

■i . -T-v A-i w > Hodges Closed Lever Pessary. 

is shown in lig. 21 3. 

To Hodge's pessary there are two objections: one is that it lacks a 

23 




434 



POSTERIOR DISPLACEMENTS OF THE UTERUS. 



point of resistance at the outlet of the pelvis, which prevents it from 
turning around ; the other is that it does not carry the body of the 
uterus high enough up in some cases. These defects Dr. Albert H. 
Smith has well met in the modification of Hodge's instrument which is 
shown in Fig. 214. 

We likewise very commonly employ, in cases in which we desire to 
carry the retroflexed fundus very high in the pelvis, the instrument 
shown in Fig. 215. 

It is a long and narrow instrument, surmounted at its upper extrem- 
ity by a bulb, and measures between its branches at the widest part 

Fig. 214. 





Albert H. Smith's Pessary 



seven-eighths of an inch in the smallest sizes, and one and one-eighth 
of an inch in the largest ; upon its upper extremity is a bulb which 
prevents cutting of the tissues ; its lower extremity rests against the 
tissues under the pubes ; and it is five inches long in the largest sizes 
and four and a quarter in the smallest, measured along the outside 

curve of the branches. Spanning 
the pelvis, this narrow instrument 
stretches the vagina without dis- 
tending it, and pushes the fundus 
to a higher point than any other 
with which we are familiar. Its 
retention depends not upon its size, 
but its relation to the pelvis, for it 
is prevented from escaping not by 
separation of its branches, but by 
the length and degree of the post- 
uterine curve, and by the retention 
established by the tissues under the 
pubes against the downward curved 
lower extremity. 

The same instrument is also very 
cleverly made by Mr. Otto of New 
York of elastic spiral wire, covered with soft rubber and ending in a 
soft-rubber cushion or bulb at its upper extremity, as shown in Fig. 
216. 

The different varieties of the lever pessary (Figs. 213-216) can be 
inserted, after the reposition of the uterus, with the patient in the dor- 
sal position, but much better and easier when she lies on her left side 




Thomas's Retroflexion Pessary. 



METHODS OF RETENTION— PESSARIES. 



435 



(Sims's position), when the pessary is introduced inverted into the ante- 
rior vaginal pouch, and by a quick motion of the right index finger is 



Fig. 216. 




Elastic Bulb Pessary. 



turned and drawn behind the cervix. This manoeuvre is difficult to 
describe, but can easily be understood by demonstration on the subject. 
A detailed description of the methods of choosing and inserting the 
numerous varieties of vaginal pessaries now in use, with all the minu- 
tiae attending their employment, will be found in Munde's Minor Sur- 
gical Gynecology, pp. 350-398. 




To a limited degree support may in these cases be obtained by the 
elastic ring pessary of Meigs, which has been as variously altered 



436 



POSTERIOR DISPLACEMENTS OF THE UTERUS. 



Fig. 218. 




Meigs's Elastic Ring Pessary. 



Fig. 219. 



as the lever of Hodge, but this instrument in posterior and anterior 

displacements is only palliative and im- 
perfect in mechanism. 

Nevertheless, this ring, imperfect as 
it is, cannot be discarded by the gyne- 
cologist, for in some cases it answers 
a purpose which no other instrument 
can be made to do. To one unaccus- 
tomed to the use of pessaries the sim- 
plicity and elasticity of this instrument 
will prove very seductive, and lead to 
a belief in its perfect harmlessness. 
Such a reliance will prove utterly delu- 
sive. Even the most elastic instrument 
will often cut through the vaginal walls 
when it is a little too large. It is in- 
deed more liable to produce this result 
than any other variety of pessary. 

These are the instruments which we employ in ordinary cases of 
posterior displacement of the uterus. There are other varieties, how- 
ever, which often answer an excel- 
lent purpose. Hewitt's pessary is 
an excellent one if the weight to be 
sustained be slight. If it be at all 
great, this instrument is utterly in- 
adequate to cope with it. It is not 
simply inefficient ; it is in such cases 
a dangerous instrument, for, resting 
against the soft parts covering the 
symphysis pubis, it may, as we have 
seen it do, cut directly through. 

In a certain number of cases the 
displaced uterine body is so heavy 
and presses so forcibly downward that a pessary of ordinary size is driv- 
en out of the vagina or so low down as to allow descent of the fundus. 
This might be obviated by employing an instrument of large size and 
great expansion of limbs, but this the vagina cannot tolerate. It sets 
up ulceration and creates pain from pressure and distension. In other 
words, without a very firm base the uterus forces out the instrument ; 
with a sufficiently firm base to resist this, ulceration from excessive 
pressure results. In some cases, indeed, so very great is the pressure 
exerted by the displaced uterus that no purely internal support will 
answer the purpose of sustaining it, for the point against which either 
the pubic or uterine extremity of the instrument rests will, in spite of 
every precaution, become ulcerated. Under these circumstances we 
have obtained the most gratifying results from the use of a modifica- 
tion of Cutter's retroversion pessary, intended to obviate a difficulty 
which we found attended that excellent instrument — that of cutting 
into the vagina. If no great amount of pressure is to be borne, 
Cutter's pessary answers very well for this purpose ; if great pressure 




Hewitt's Pessary. 



METHODS OF RETENTION— PESSARIES. 437 

is to be borne, the point of his instrument endangers the tissues. For 
this reason we have affixed to the top of Cutter's pessary bulbs of dif- 
ferent sizes — some as large as an olive — for the object is not only 
to prevent cutting of the vagina, but to place behind the displaced fun- 
dus a mass which will make it fall forward by displacement, and not by 
pressure. Our alteration of this instrument is insignificant ; the entire 
credit of it belongs to Dr. Cutter, to whom the profession is indebted 
for affording it so valuable and simple a method for meeting the dif- 
ficulties of aggravated retroversion. Had we space we could cite a 
number of very bad cases of this difficulty which had for years resisted 

Fig. 220. Fig. 221. 





Cutter's Pessary. Thomas's Modification of Cutter's Pessary. 

treatment by ordinary pessaries, and which have readily yielded to the 
use of Cutter's instrument or this modification of it. The inferior ex- 
tremity of this pessary arches backward over the coccyx, and attaches 
to an elastic cord which passes upward over the sacrum to a girdle 
around the waist. It is a painless and efficient method of giving sup- 
port, and will gain a high reputation on account of these qualities in 
posterior displacements. The class of cases to which it is especially 
applicable is that in which the displacement is due to prolapse of the 
posterior vaginal wall from rupture of the perineum or other cause. 
When employed for posterior displacements, the upper extremity of 
the instrument simply lies in the fornix vaginae, the cervix of course 
not entering the fenestra. 

This instrument should be removed every night and reinserted 
every morning. It may be said that this will prove difficult of accom- 
plishment for the patient. Out of hundreds of cases in which we have 
used it we have never found an instance of failure in this respect. The 
patient will very often become disaffected toward the instrument from 
its chafing the perineum. By a little patience, covering the points 
which rub with greased lint, and leaving the pessary out until the irri- 
tated part be healed, the feeling will soon pass away. 

It will be observed that thus far we have dealt, in treating of the 

mechanical means for sustaining the flexed uterine body, with those 

•which directly push the fundus upward, in the hope that in time it will 

fall forward of its own weight and assume a natural position. In some 

cases this is not enough ; Ave are forced to do that at the same time that 



438 



POSTERIOR DISPLACEMENTS OF THE UTERUS. 



Fig. 222. 



we elevate as far as possible the cervix into the hollow of the sacrum, 

and thus increase the liability of the 
uterine body to fall forward. In 
other words, there are two forces 
which may, through a pessary, over- 
come retroflexion : first, that which 
pushes the corpus uteri upward and 
forward ; second, that which pushes 
the cervix upward and backward. 
The first of these often proves quite 
sufficient without the second, but 
sometimes the direct and steady 
pressure upon the uterine body in- 
volved in it becomes intolerable. 
Then is it that the second, which 
alone is never sufficient, comes into 
play as an efficient adjuvant. We 
have often seen the practice of the 
double method effect cures which 
seemed to have been impossible by 
that of a single one. We deem 
this point of sufficient importance 
to illustrate it by schematic dia- 

Force applied to Uterine Body alone. grams. 

By these means a uterus affected 
by a reducible retroflexion may, in all conditions excepting the unfa- 

Fig. 223. 





Force simultaneously applied to Cervix and Body. 

vorable ones already mentioned, be restored to its place and kept 




METHODS OF RETENTION -PESSARIES. 439 

there without resort to the intra-uterine stem or a cutting operation. 
These unfavorable conditions we will 
now consider. 

When the vagina unites itself to 
the cervix so near its lowest point as 
to leave almost no post-cervical space, 
it is impossible to sustain the uterus 
by any vaginal pessary. Under these 

circumstances, and these alone, We be- Retroflexion Pessary with Cervical Rest. 

lieve the intra-uterine stem to be neces- 
sary in posterior displacement. Those which were recommended in 
anteflexion will answer here. 

Anteflexion is probably often a congenital condition, or continues 
for so long a period during the life of the girl before it is discovered 
that the anterior inflexion becomes an irreducible uterine deformity, 
This is sometimes — though much less frequently so in retroflexion, 
which is usually reducible unless the flexed body be bound down by 
false membranes — the result of slight peritonitis. It is sometimes dif- 
ficult in a given case to decide the cause of the permanency of the dis- 
placement. In a general way it may be said that if it be due to false 
membranous attachment, the uterus will not move from its position in 
the pelvis ; if it be due to contraction in the tissue of the uterus itself, 
the organ will change its pelvic relations, but not the abnormal ones 
existing between body and neck. 

In case the flexion be found due to parenchymatous alteration, 
no surgical procedure should be adopted ; but the body should be 
cautiously bent forward once or twice a week by means of the 
sound or repositor, and kept in anterior inclination by means of the 
retroflexion pessary shown in Fig. 224 or by the modified Cutter's 
pessary. 

If the uterus be found fixed in the position of retroflexion by false 
membranous attachments not of recent origin, and the patient be not 
suffering to such an extent from the displacement as to render reposi- 
tion urgently necessary, it had better be left undisturbed in its unnat- 
ural place. Should the disorder, however, be affecting the health or 
causing such pain and discomfort as to render the incurring of the risk 
of peritonitis warrantable, reduction should be accomplished in this 
way: The patient having been anaesthetized and placed in the left 
lateral position, the sphincter ani should be stretched by the thumbs. 
Then the index and middle fingers of the right hand should be passed, 
with the palmar surfaces toward the sacrum, up the rectum to the flexed 
uterine body. Steady pressure should then be made upon it until the 
organ is lifted upright, when, the fingers being made to describe the 
arc of a circle toward the pubes, the outer surfaces of the finger-nails 
will be in contact with the uterine body, and by them it will be pushed 
over into an anterior position. After this the fornix should be filled 
with a soft, moist sponge, and this be forced up so as to sustain the 
body by a tampon of cotton in the vagina. After this the patient 
should be kept very quiet for a week, and all pain should be soothed 
by free use of opium as a preventive of peritonitis. 



440 POSTERIOR DISPLACEMENTS OF THE UTERUS. 

Schultze 1 has especially recommended the bimanual detachment 
under anaesthesia of the retroverted, displaced, and adherent corpus 
uteri. We have practised this method a number of times with fair 
success, but think it practicable only when the adhesions are either 
fresh or trifling in extent. 

In cases where the body of the uterus and the appendages are both 
adherent, and the symptoms (pain, dysmenorrhea, sterility) urgently 
call for relief, of late years the proposal has been made by Olshausen, 
Sanger, Kelly, and others, and followed by the majority of other 
laparotomists, to open the abdominal cavity in the usual way, and by 
the fingers, introduced through the opening, peel loose the adherent 
uterus and appendages, and stitch the fundus uteri to the anterior 
abdominal wall. This operation has been called " ventro-fixation," 
" abdominal hysteropexy," and. " hysterorrhaphy " by its various advo- 
cates. It is evident that the dangers always and inevitably accom- 
panying an abdominal section (peritonitis, septicaemia, intestinal obstruc- 
tion) are necessarily attached to this operation. Hence it should not 
be performed lightly or carelessly. We have done it a number of 
times, with very good results (one subsequent pregnancy with abortion 
at four months. — P. F. M.), but feel somewhat inclined to limit it to 
those cases where the diseased ovaries and tubes form the chief indica- 
tion for the operation, the backward displacement being of secondary 
importance. Here we not only stitch the fundus uteri, scraped raw 
with the knife, but also the pedicles of the appendages, to the ante- 
rior abdominal wall. 

For cases of retro-displacement which proved intractable to the forms 
of support described above, and still called for relief, Alexander 2 of Liv- 
erpool in 1881 revived an operation previously hinted at by Aran and 
Alquie in France, Freund in German} T , and Adams in England, con- 
sisting in opening the inguinal canal on each side of the pubis, catch- 
ing up and drawing out the round ligaments until the fundus uteri 
touches the anterior abdominal wall, sewing the ligaments firmly into 
the canal, and cutting off their excess. The uterus is supported by a 
vaginal pessary for some months, until the ligaments are firmly attached 
in their new relations. We (P. F. M.) have performed this operation 
nearly forty times (first in 1884), and believe in its usefulness and per- 
manent results most decidedly. Several of our patients have even 
conceived, carried to term, and been delivered without the uterus again 
retroverting. Be it understood that this operation does not conflict 
Avith that of ventro-fixation, since Alexander's operation is indicated 
only when the uterus is freely movable and the appendages are normal. 
One objection to it is the uncertainty of finding the round ligaments 
sufficiently strong to support the elevated uterus. For details as to 
the technique see Alexander's book and Munde. 3 

1 Schultze, he. cit. 

2 Alexander, The Treatment of Backward Displacements of the Uterus and of Prolapsus 
Uteri by the New Method of Shortening the Round Ligaments, London, 1884. 

3 Munde, " The Value of Alexander's Operation, estimated from the results of 23 
cases," Am. Journ. Obst., Oct., 1888. 



INVERSION OF THE UTERUS. 441 

Latero-flexion. 

Sometimes the uterus is flexed to the right or left side as a conse- 
quence of disease of its proper tissue or of direct pressure. This 
variety of displacement rarely attains to such a degree, however, as to 
result in obstruction of the uterine canal. Its chief importance is 
connected with diagnosis, for it may readily be mistaken for peri-ute- 
rine inflammation or a fibrous tumor. The practice of conjoined 
manipulation and the use of the uterine probe will always settle the 
point. 

The treatment of latero-flexion should be conducted upon precisely 
the same principles which guide us in reference to anteflexion and retro- 
flexion. Of all varieties of flexion, this is the most likely to require 
the use of the intra-uterine stem, for it is exceedingly difficult — we 
may even say rarely possible — to overcome it by a vaginal instrument. 
When this necessity presents itself, either in retroflexion or latero- 
flexion, we employ the intra-uterine stem represented in Fig. 200. 
The fundus is in part sustained by the pessary, not entirely by the 
stem. 

After the introduction of every pessary the position of the uterine 
body should be at once examined, either by the probe, by conjoined 
manipulation, or by both, to ascertain whether the instrument be 
efficient or not. If it be not so, it is imperfect, for the object is not 
to go through the form of introducing a pessary ; it is to rectify the 
malposition of the uterus. At the next and at every subsequent visit 
of the patient this examination should be made before removal of the 
instrument, in order to test the effect of time and movement upon the 
position of the supported uterus. 



CHAPTER XXXI. 

INVERSION OF THE UTERUS. 

Definition. — This dangerous and infrequent form of displacement 
consists in the turning of the uterus inside out. As the bottom of a 
bag may be pushed through its mouth, so that the inner surface becomes 
the outer, so may that of the uterus, and the occurrence of such an 
accident constitutes the disease which we are considering. 

Varieties. — Writers differ in classifying the varieties of the affec- 
tion, some describing three and some four forms. For practical pur- 
poses all these may be brought under two heads — partial and complete. 
In the first the body has become depressed, but has not passed through 
the os. In the second the uterus has been turned completely inside 
out, and the inverted fundus and body hang in the vagina or, if the 
vagina also is inverted, between the thighs — cw vehit scrotum," as it has 
been expressed by Hippocrates. Fig. 225 represents the first, and 
Fig. 226 the second form of the accident. 



442 



INVERSION OF THE UTERUS. 



In addition to these varieties the accident must be divided into 
acute and chronic, or sudden and gradual inversion, as it occurs rapidly 
or slowly. 

Anatomy. — In treating of flexions of the uterus it was remarked 
that they are chiefly prevented by the resisting nature of the parenchyma 
of the cervix which supports the fundus and body. A similar function 
on the part of the entire uterine structure keeps the cavities of the neck 



Fig. 22c 



Fig. 226. 



J 





Partial Inversion. 



Complete Inversion. 



and body closed and prevents inversion. Should that power which in 
the pregnant uterus we call contractility, and in the non-pregnant tone, 
be to any great degree impaired, the body of the organ, bereft of sup- 
port, will incline forward or backward. Should it be entirely abol- 
ished, the fundus under the influence of traction or downward pressure 
may pass through the unresisting os and escape into the vagina, con- 
stituting inversion. 

[I once saw this perfectly illustrated in a cadaver upon which I was 
called to perform version soon after death. As I extracted the child the 
flaccid uterus followed it directly, and was completely inverted, the placenta 
still adhering.— T. G. T.] 

[I also saw this occur during the past winter while evolving by traction 
a sessile fibroid attached to the fundus uteri ; the whole organ was inverted, 
with the vagina, and lay outside the vulva, with the tumor still attached 
to the fundus. After enucleating the tumor I manually reinverted the 
uterus. 

Winckel 1 says: "I am not aware of any recorded case in which inver- 
sion had been observed to follow traction used in extracting a polypus in 
the same way as it may be caused by traction on the umbilical cord. This 
is improbable, as in such cases the polyp is seldom larger than a hen's egg 
and the pedicle usually thin." I am surprised at this statement, for I have 
seen partial inversion produced a number of times, indeed usually, when 
traction was required to render the pedicle of the polypus accessible, and in 
the above case the inversion was complete, and I had some difficulty in 
restoring the organ. — P. F. M.J 

Pathology. — The accident depends for its production upon two ele- 
ments — 

1 Loc. eit., p. 335. 



PATHOLOGY. 443 

1st. Relaxation and inertia of the uterine walls ; 
2d. Downward traction or pressure. 

The first of these may be a primary and original state, or it may 
be induced by the second after months of exhausting action. For 
example, after labor the uterine walls may remain lax and atonic from 
inherent inertia ; or their tissue in the non-pregnant state may be firm 
and resisting, yet in time be overcome by the traction and dilatation 
exerted by a large fibrous polypus attached to the fundus. 

In the limited space which we can allot to this subject it is impossi- 
ble to present the various theories which have been advanced for the 
explanation of the mechanism of inversion, nor would it be beneficial 
for the student that we should do so. In place of such an effort we 
shall mention those which appear to us to possess really important and 
practical bearing upon the subject. 

The three views to which we shall direct attention are the following : 

1st. That some part of the relaxed body prolapses, and, passing 
out of the cervix, drags the entire uterine body with it. 

2d. That some part of the relaxed body, prolapsing, acts as an 
excitant of uterine contraction, which forces the remaining portion 
through the cervix, and thus inverts the whole organ. 

3d. That lateral traction and direct pressure on a cervix the tissue 
of which is abnormally soft causes eversion of this part and gradually 
of the whole uterus. 

The first of these is the oldest, and even at present the most gen- 
erally received, view as to the mechanism of inversion. According to 
it, it was generally supposed that the part of the fundus which first 
undergoes inversion is the middle. This is denied by Oldham and 
Kiwisch, who maintain that one horn first inverts itself, and is followed 
by the fundus, the other horn, and then the entire body. 

[I have met with one case which proves incontestably that, even if this 
be not a rule, inversion at least occurs in this manner sometimes. A patient 
who for several years had suffered from monorrhagia applied to Prof. C. A. 
Budd of this city for treatment. Upon examination he discovered what he 
supposed to be a fibrous polypus equal in size to a hen's egg attached to the 
uterine cavity near the entrance of the right Fallopian tube. Carefully 
differentiating this, as he supposed, from partial inversion, he applied the 
ecraseur and removed it, when he discovered that he had removed one horn 
of the uterus with a part of the corresponding Fallopian tube and round 
ligament. The case, which was one of partial inversion, was not susceptible 
of diagnosis. The menorrhagia attending it was entirely relieved by the 
operation, the patient rapidly recovering. — T. G. T.] 

When the accident begins in this way the inverted horn pulls down 
the other parts with greater or less rapidity, and thus the method of 
occurrence may be lost sight of. Rokitansky, in speaking of irregular 
post-partum uterine contraction, thus describes partial inversion, with 
which he has twice met: "We must here mention a very singular cir- 
cumstance which may, on account of the consequent danger, become 
important, and may even be misunderstood in post-mortem examinations : 
it is paralysis of the placental portion of the uterus occurring at the 
same time that the surrounding parts go through the ordinary processes 



444 INVERSION OF THE UTERUS. 

of reduction. It induces a very peculiar appearance. The part which 
gave attachment to the placenta is forced into the cavity of the uterus 
by the contraction of the surrounding tissue, so as to project in the 
shape of a conical tumor, and a slight indentation is noticed at the cor- 
responding point of the external uterine surface. The close resem- 
blance of the paralyzed segment of the uterus to a fibrous polypus may 
easilv induce a mistake in the diagnosis, and nothing but minute 
examination of the tissue can solve the question. The affection always 
causes hemorrhage, which lasts for several weeks after childbirth, and 
proves fatal by the consequent exhaustion." 

Since the days of Astruc the theory has been at various times main- 
tained that active contraction of the uterus sometimes produces inver- 
sion. ' ; Sometimes," says Astruc, "it is produced from contraction of 
the womb, which forces the bottom inside out through the mouth of 
the womb, which is not yet closed." Regular uterine contraction, 
however violent it may be, would only tend to complete closure of the 
uterine cavity. If, however, such a partial inversion or internal pro- 
jection as that alluded to by Rokitansky in the quotation recently 
made occur, it acts as the placenta, the hand of the obstetrician, or any 
other body in the cavity, by exciting expulsive efforts which may suc- 
ceed in driving it out of the os externum. Should they do so, com- 
plete inversion is the result ; should they fail, the projection may persist 
as a partial inversion. This view, which was advocated by the late Dr. 
Tyler Smith, appears to me to explain the apparent paradox of inver- 
sion with tonic contractions of the uterus, more satisfactorily than any 
other which has been advanced. We have met with one case occurring 
after delivery which convinces us that sometimes, at least, what we 
have just described really takes place. 

Still another and very ingenious theory has been advanced by Prof. 
I. E. Taylor for explaining the occurrence of inversion. It is that 
inversion sometimes begins at the cervix, this part undergoing ever- 
sion as in prolapsus, and this going on to the complete inversion of the 
entire organ. 

In previous literature allusions to the possibility of inversion after 
this method may be found. Klob alludes to it in these words : "A 
very remarkable class of cases of inversion are those in which, without 
efficient cause, an inversion of the cervix into the vagina takes place, 
drawing the fornix of the latter with it, and thus forming a polypus- 
like tumor in the cavity of the vagina, which may reach down to the 
vulva, at the lower part of which the internal orifice is situated." A very 
striking case was published by Mr. "William Lawrence in the London 
Medical Gazette, Dec. o, 1838, under the head of " Spontaneous Par- 
tial Inversion of the Uterus." But the credit of having drawn proper 
attention to the subject and having proclaimed its probable pathological 
bearings unquestionably belongs to Taylor. "We say "probable," for 
the reason that it is not yet proved. "We accept it, because our own 
observation leads us to believe that Dr. Taylor's deductions are prob- 
ably correct. 

The majority of non-puerperal inversions are undoubtedly produced 
gradually by the efforts of the uterus to expel a submucous tumor sit- 



EXCITING CAUSES. 445 

uated at some point above the internal os, preferably at the fundus. 
Scanzoni demonstrated this fact in an able and elaborate paper pub- 
lished in 1867. 1 

Predisposing Causes. — Every influence which destroys the tone and 
resistance of the uterine parenchyma proves a predisposing cause of this 
condition. As examples may be mentioned — 

Parturition ; 

Distension of uterus by retained fluids ; 

Distension of uterus by tumors ; 

Spongy softening of tissue in prolapsus (?). 
Exciting Causes. — A uterus in which the tone of the walls has been 
destroyed by physiological, pathological, or mechanical causes has lost 
all its normal safeguards against inversion. Thus, we may say that 
anything which produces distension and relaxation of the tissue of the 
uterus prepares the way for inversion so completely that a very triflng 
exciting cause may produce it. For example, any decided traction or 
pressure exerted upon the fundus of a uterus thus affected, even to a 
limited degree, may directly result in it. The exciting causes are thus 
presented : 

Traction on placenta ; 

Traction by polypi or tumors ; 

Sudden delivery of child by traction ; 

Muscular efforts when relaxation exists ; 

Prolapsus uteri (?). 
Instances of its production by all these causes are on record, though 
by far the greatest number of cases has followed parturition. Of 400 
cases collected by Dr. Crosse of Norwich, England, 350 followed deliv- 
ery, and of the remaining 50, 40 were due to polypi. This dispropor- 
tionate frequency does not, however, invalidate the fact that the other 
causes mentioned have resulted and may result in the accident. Most 
frequently it occurs very soon after delivery, though Ane and Baude- 
locque report its having taken place on the third, and Leblanc on the 
tenth, day. 

Traction and relaxation, when combined, are evidently sufficient for 
the induction of the accident, and it is generally to a union of the two 
that it is due. The question now arises whether either of them alone 
can cause it. With reference to the efficiency of the second element, 
the answer may be affirmative, since with complete relaxation inversion 
may occur from a very insignificant exciting cause, as coughing, sneez- 
ing, or a change of posture. As to the possibility of any amount of 
force inverting the non-pregnant and undilated uterus much doubt has 
been expressed. At first thought every one will feel inclined to express 
a decidedly negative opinion, but the evidence On record in favor of 
such a possibility is too strong to be entirely ignored. A portion of it 
is therefore laid before the reader. 

Puzos 2 in 1744 read before the Academy of Medicine of Paris a 
memoir in which he declared that he had seen the accident in women 
who had never borne children. Boyer 3 cites a similar example in a 

1 Scanzoni's Bertrage, 1867. 2 Coluuibat on Females, Meigs, p. IS-. 

3 Tvaite des Mai. chirurgieaies. 



446 IXVEBSIOX OF THE UTERUS. 

female whose uterus contained no foreign body, and Daillez 1 tells us that 
Baudelocque met with a case in a girl fifteen years of age in whom 
clandestine delivery could not have occurred, since a perfect hymen 
existed. 

It may, perhaps, not be ungracious to doubt the correctness of the 
diagnosis in these ancient cases, since recent literature gives us well- 
authenticated cases of inversion of the virgin uterus unaccompanied by 
the tractile force of a fibrous tumor. Winckel says (Joe. cit.) : " Polk 
has reported an inversion of the virgin uterus, but it is doubtful whether 
the diagnosis was really correct." 

[Prof. Willard Parker of New York furnishes me with the history of the 
following case : A young woman who had borne one child seven or eight 
years previously, and had never had any recognized uterine disease, while 
making a violent effort in rolling tenpins suddenly felt something give way 
within her, after which she suffered the most intense pain and became com- 
pletely disabled. Dr. Parker, being called to see her, after a hasty examina- 
tion coincided with the opinion of the attending physician, that a polypus 
had been suddenly expelled and was hanging in the vagina. Impressed with 
this belief, he removed the whole mass, when, to his surprise, he found that 
he held in his hands the inverted uterus with its tubes and ligaments. The 
patient recovered without any bad symptoms, and subsequently menstruated 
regularly.— T. G. T.] 

Menstruation after amputation of the uterus is by no means rare. 
It must be remembered that in such an operation the whole uterus is 
not removed. It is from the remaining stump that the flow occurs. 

After all, there is nothing more astounding in the fact of spon- 
taneous inversion of an undistended uterus than there is in the spon- 
taneous reposition of one which has been long inverted ; and this we 
have, with the positive testimony of scientific and reliable men now on 
record, no possible justification for doubting. Of late the validity of 
both these phenomena has been denied. There is nothing easier than 
the rejection of the testimony of others and the discrediting of deduc- 
tions which we ourselves have not drawn. "When De la Barre pre- 
sented his case of spontaneous reposition to the Academy of Surgery, 
Baudelocque was appointed a committee to examine into it, and 
reported that it was "totally false." Some years afterward he met 
with a very similar case, and yielded to the evidence of his own senses 
a credence which he had presumptuously denied to the assertions of 
another. Spiegelberg reports a case of spontaneous rein version while 
the patient was straining at stool. 

Symptoms. — Should inversion occur suddenly — as, for instance, 
after delivery — the patient will complain of discomfort about the 
vulva, faintness, and nervous disturbance. Hemorrhage and tend- 
ency to collapse will show T themselves, and unless proper treatment be 
adopted at an early period death may ensue. A physical examination 
will at once- settle the diagnosis, for a large, flabby, globular mass, per- 
haps with the placenta attached to it, will be found between the thighs 
of the patient if inversion be complete. But very often no diagnosis 
will have been made at the time of its occurrence, and months, perhaps 

1 Colombat, op. cit. 



PHYSICAL SIGNS. 



447 



years, afterward the physician will be called upon to determine the 
character of the case, which will probably present the following 
symptoms : 

Occasional or constant hemorrhage ; 

Dragging pains in back and loins ; 

Difficulty in locomotion ; 

Difficulty in defecation and micturition ; 

Anaemia and its accompanying evils. 
Physical Signs. — All these s}^mptoms belong as much to polypus, 
fibrous tumor, and cancer as to inversion, and to determine their true 
cause physical exploration is indispensable. Should the inversion be 
complete, the finger, being introduced into the vagina, will meet with a 
tumor, which the examiner will at once know is either the displaced 
body of the uterus or a polypus, and his attention will be directed to 
their differentiation. 



IF IT BE A POLYPUS — 

The probe will usually pass by its side 

into the uterus ; 
Conjoined manipulation will reveal the 

uterine body ; 
Rectal examination will reveal the uterus 

in situ ; 
Recto-vesical exploration will reveal the 

uterus ; 
Acupuncture will give no pain. 1 



IF IT BE INVERSION — 

The probe will be arrested at the neck ; 

Conjoined manipulation will reveal a ring 

where the uterus should be ; 
Rectal examination will not reveal the 

uterus in situ; 
Recto-vesical exploration will not reveal 

the uterus; 
Acupuncture will give pain. 



Fig. 22^ 



In certain very rare cases a large fibrous tumor growing from 
one lip of the cervix will lead to the belief in inversion in the fol- 
lowing manner : the pedicle setting up inflam- 
mation in the cervical canal, complete adhesion 
takes place, so that a probe can nowhere be 
passed. An examination of Fig. 227 will read- 
ily explain how such a state of things might 
arise and prove exceedingly perplexing. We 
have seen several such cases, in all of which 

Fig. 22S. 





Polypus. 



Inversion. 



recognition of the presence of the uterine body above emboldened 
us to work the probe through the tissue around the pedicle of the 

1 Gueniot, Arch. gin. </<' Med., 1868, t. ii. p. 393 : a doubtful sign. 



448 



INVERSION OF THE UTERUS. 



growth, causing it to enter the uterus and thus prove ineontestably the 
nature of the case. 

Should the inversion be incomplete, diagnosis will always prove 
difficult, and in fat women particularly so. Differentiation from a 
fibrous tumor will depend upon the following signs : 



IF IT BE A FIBROID GROWTH — 



IF IT BE PARTIAL INVERSION — 



The probe will show increase of uterine ! The probe will show diminution of uterine 

cavity ; cavity ; 

Conjoined manipulation per vaginam and : Conjoined manipulation per vaginam and 

rectum will reveal rotund body of uterus ; | rectum will reveal small abdominal ring ; 
It will have come on very gradually ; I It will have occurred more suddenly ; 

It will have no reference to parturition ; It usually follows parturition ; 
Acupuncture is painless(?). | Acupuncture gives pain(?). 

A partial inversion of a non-puerperal uterus, unattended by the 
presence of a fibrous polypus as the predisposing and' exciting cause, 
does not occur, or at least is scarcely likely to come under observation. 



Fig. 229. 



Fig. 230. 





Fibrous Polypus. 



Partial Inversion. 



It is only when the inversion has been completed that the symptoms 
induce the patient to seek medical advice. Hence in cases of partial 
inversion there will always be found a fibrous tumor forcing its way 
out of the uterus, and drawing the uterine wall after it. 

Course, Duration, and Termination. — All these are very variable. 
The accident occurring after delivery may rapidly, unless relieved, pro- 
duce death by hemorrhage and exhaustion ; or it may continue for 
many years, giving very little annoyance ; or, again, it may render the 
life of the patient miserable on account of hemorrhage and other 
attending smyptoms, and nevertheless last for years. As a rule, it 
may be stated that inversion continues until relieved by treatment, and 
yet even this is not without exceptions. The womb has been known 
under these circumstances to replace itself by its own contractions years 
after its occurrence when the accident has happened after delivery. 
Twelve such cases have now been placed upon record : three by Meigs, 1 



1 Obstetrics. 



PROGNOSIS. 449 

and one by each of the following observers : Spiegelberg, 1 Leroux, 1 
De la Barre, 1 Thatcher, 1 Rendu, 1 Shaw, 1 Baudelocque, 2 Foujen, 3 and 
Huckins. 4 Even admitting the undoubted authenticity of these cases, 
spontaneous reduction must be regarded only as a curiosity, and not as 
a process to be anticipated. 

Prognosis. — The prognosis of chronic inversion is at all times grave. 
Repeated and prolonged hemorrhages prostrate the patient and expose 
her to all the risks of the worst forms of uterine polypus. But not 
only is she exposed to dangers inherent to the displacement from which 
she suffers ; those attendant upon an erroneous diagnosis are very great. 
To one alive to the possibility of confounding the condition with fibrous 
polypus, the methods of differentiation are numerous and reliable ; but 
to the rapid and careless diagnostician, w T ho does not allow the possi- 
bility of error to enter his mind, and consequently does not carefully 
weigh the evidence, there is a great likelihood of it. 

One who is aware of the great frequency with which amputation of 
the inverted uterus has been practised under the impression that a 
fibrous polypus was being removed, cannot but wonder that errors of 
diagnosis have so often occurred when so many methods of differentia- 
tion were at command. The explanation is that to which we have 
referred — namely, that the possibility of error was not entertained. 
Out of 58 cases of inversion of which a report is given in the Bei- 
trclge zur Geburtskunde tend Grynakologie, and in which amputation 
was practised, 7 w T ere mistaken for polypi. 

[I have treated personally 9 cases of inversion, of which 6 resulted from 
parturition and 3 from traction by sessile polypi. Of these, 7 were cured 
by replacement; 1, in the case of a very old and feeble woman, was left 
unreplaced, after removal of a sessile fibroid, which gave complete relief; 
and 1 case after replacement ended fatally from peritonitis. — T. Gr. T.] 

Even where a correct diagnosis has been made, still another danger 
menaces the patient — that of rupture of the vagina in attempts at 
reduction of the inverted organ. A small hand, a cautious, unexcitable 
mind, and constant vigilance during all the efforts by taxis must be com- 
bined with thorough knowledge of the subject to avoid this imminent 
danger. Even with this combination it is a matter of surprise to us, from 
our experience with these cases, that the accident has not occurred much 
oftener. We confess that we should prefer to trust a patient in whom 
we felt great interest to the operation of abdominal section, which is 
hereafter described, than to that of prolonged taxis at the hands of a 
rough, unintelligent, and inexperienced practitioner. To one thinking 
upon this subject for the first time this position will appear exaggerated 
and indefensible, but we assume it after mature reflection. 

When the prospect of returning the uterus seems brightest the prac- 
titioner is sometimes disappointed by the existence of adhesions. Thus 
Velpeau, 5 after the removal of a polypus attached to an inverted uterus. 

1 Article by Prof. Spiegelberg in Archiv fur Gynakologk—Am, Journ. Obstet. } Aug.. 

18/ 3. 

2 Daillez, Thesis. 3 Weiss, Des Reductions de F Inversion, etc. 
* Letter to author from T)r. Jason Huckins of Maine, Q, S. 

5 Becquerel, op. cit., p. 301). 
29 



450 INVERSION OF THE UTERUS. 

was completely foiled in restoring it, and the patient died from perito- 
nitis. 

Treatment. — In the treatment of inversion three methods may be 
adopted : 

1st. The organ may be left in malposition, hemorrhage being con- 
trolled by hemostatic means. 

2d. The inversion may be reduced by taxis, by elastic vaginal 
pressure, or by a combination of the two. 

3d. All these failing to give relief, the uterus may be amputated. 

Methods of Checking Hemorrhage, the Uterus being Left in SitH. — 
Should the operator fail in repeated attempts at reduction, it becomes a 
question whether he should amputate the displaced organ or leave it in 
its abnormal position and endeavor to combat the evils resulting. The 
greatest of these is unquestionably hemorrhage, which steadily exhausts 
the patient : but others of less moment arise from dragging of the ute- 
rus upon its ligaments and the mechanical inconvenience of a tumor in 
the vagina. If the patient be near the menopause, both of these may 
diminish by atrophy and cessation of menstruation. Should she be 
young, artificial means may, in a limited degree, accomplish the same 
results. 

The most vascular growths — such, for example, as hemorrhoids and 
mevi — may be diminished in size and rendered non-hemorrhagic by 
astringents or caustics, which destroy their superficial varicose vessels 
and leave a less vascular tissue beneath. The inverted uterus may be 
similarly acted upon, not only in checking hemorrhage, but in pro- 
ducing atrophy, and thus removing to a certain extent the two sources 
of suffering. 

Solutions of alum, tannin, persulphate of iron, or acetate of lead 
may with advantage be injected into the vagina so as to bathe the 
uterus freely, or they may be placed in contact with it by means of 
pledgets of cotton. Should these fail in checking the flow, a plan pro- 
posed by Aran, of applying caustics to the whole bleeding surface, may 
be resorted to. The tumor being drawn down and exposed to view as 
much as possible, its surface is seared by the actual cautery or touched 
by potassa cum calce or the mineral acids. The organ, after being 
bathed in a neutralizing fluid, is then enveloped in lint, so as to protect 
the vaginal walls, and placed within the pelvis. We have never seen 
the method employed, but would not hesitate in an appropriate case to 
venture upon it. Aran declares that not only is hemorrhage checked 
by it, but great diminution of the tumor effected. The procedure 
recommends itself as eminently rational, and when it is remembered 
that the only recognized alternative is amputation, the propriety of 
giving it consideration must be admitted. 

Many cases are on record in which the uterine mucous membrane 
has become altered so as to resemble skin, and in which the patients 
have lived without suffering for many years. Dr. Alexander H. Ste- 
vens had one case under observation for more than thirty years ; Dr. 
Charles A. Lee diagnosticated one which had remained undetected for 
twenty-five years ; and the works of older writers offer many other 
examples. If we can bring about a similar condition by artificial 



METHODS OF REPLACING THE UTERUS. 451 

means and avoid the operation of ablation, we will certainly be acting 
in the best interests of the patient. It is for this purpose that cau- 
terization offers itself as a resource. 

Methods of Replacing the Uterus. — It is not certainly known 
whether the condition of inversion of the uterus was properly under- 
stood before the time of Ambrose Pare\ Since his epoch it has been 
fully described by his successors, and all its pathological features, its 
various symptoms, and its manifold dangers have been thoroughly 
appreciated. From the time of Pare*, who lived about the beginning 
of the seventeenth century, to our own, although great advances were 
made in the scientific department of the subject, very little was attained 
in the way of treatment. The possibility of replacing by taxis a 
uterus recently inverted was known, but for cases in which the organ 
had been displaced for years, or even for months, no resource existed 
except amputation. 

It is certainly one of the many triumphs of which the gynecology of 
the nineteenth century can boast that this accident has been proved to 
be amenable to conservative measures, and that taxis has been shown 
to be capable of effecting a cure and preventing a resort to a mutilating 
surgical procedure. 

So far as we have been able to ascertain, the first cases of chronic 
inversion which were successfully reduced by taxis are those mentioned 
by Colombat 1 in the following passage: u Dr. Daillez 2 reports in his 
dissertation that the surgeon Labarre de Benzeville had effected the 
reduction as late as the eighth month, and Baudelocque after eight 
years." In later times the first successful case occurred in 1847. 3 The 
inversion had lasted more than a year, when M. Valentin, by intro- 
ducing one hand into the vagina and making counter-pressure by the 
other over the abdomen, succeeded in reducing the displaced fundus in 
ten minutes. In 1852, Mr. Canney 3 in the same manner effected 
reduction in a case of five months' standing, and in the same year M. 
Barrier 4 accomplished it in one which had existed for fifteen months. 

Up to the year 1858 the reposition of inverted uteri may be said to 
have been limited to replacement within short periods after parturition. 
It is true that occasional cases had occurred in which chronic inversion 
had been overcome by taxis and pressure, but these held the position 
of accidental and anomalous feats in treatment, not that of systematic 
procedures, which it was incumbent upon the practitioner to' essay in 
every case. At this period two cases of chronic inversion were reduced 
— one of twelve years' standing by Prof. Tyler Smith of London, by 
elastic pressure and taxis ; the other of almost six months' standing by 
Prof. James P. White of Buffalo, U. S., by taxis alone. Each of these 
gentlemen worked without the knowledge of what the other was doing. 
and to them belongs the great credit of having systematized and made 
subservient to science and humanity a method which before had been 
practised in a loose and desultory manner. Soon after their publica- 
tions cases of cure affected by taxis alone, or combined with pressure 

1 Colombat, Am. ed., p. 186. - Daillez's Thesis appeared in L803. 

3 Quoted from Banking's Abstract, vol. vii., by G. Hewitt. 

4 Courty, Mai. de V Utinis, p. 797. 



452 INVERSION OF THE UTERUS. 

by bags of air or water placed in the vagina, were rapidly reported 
from different parts of the world. Most notable among these were the 
cases of Noeggerath, of thirteen years' standing ; Teale, of two and 
a half years ; West, of one year ; White, of fifteen years ; and Bocken- 
dahl, of six years. When it is stated that all these occurred in 1859, 
it will be fully appreciated how great an impetus was given to this 
subject by the successes of Smith and White. Within the past ten 
years cures have multiplied so rapidly as to preclude the mention of 
individual cases in a work of the character of this ; and, although we 
cannot go so far as to endorse the sanguine prediction of White, made 
in 1872, that "well-directed pressure upon the fundus, if continued 
long enough, will, in all cases where there are no adhesions, result in 
restoration or reposition," we do believe that the day has passed when 
any practitioner would be held blameless by a jury of his peers who 
has either left untouched or amputated a uterus in the condition of 
chronic inversion without some special reason apart from the mere dis- 
placement itself. 

The best methods at our command for replacing an inverted uterus 
we shall now proceed to describe, premising this description with the 
statement that we do not propose to mention all methods which have 
been adopted, but only those which are most worthy of reliance. They 
may thus be presented at a glance : 

Elastic pressure by vaginal stem and cup or 

bulb ; 
Elastic pressure by vaginal water-bag com- 
bined with taxis ; 
Elastic pressure by vaginal water-bags alone ; 
A stream of cold water. 
Manipulation by Viardel's method ; 
" " Emmet's " 

" " Barrier's " 

" " Noeggerath's " 

" " Courty's " 

" " Thomas's 

" White's " 

" Tate's 

None of these methods are free from danger ; in several cases even 
elastic pressure has excited fatal peritonitis. But gradual reposition is 
certainly much safer than rapid reduction. 

Before the practice of any of them certain preparatory measures 
calculated to relax the cervical parenchyma or render its resistance 
less decided may be essayed. One of these is the use of belladonna 
by the vagina in the form of vaginal injections of the infusion, of oint- 
ment smeared around the uterine neck, or of hypodermic injection ; or 
by the rectum in the form of suppository. The other is the making of 
two or three longitudinal incisions through the superficial layers of the 
parenchyma of the neck. This method is a very old one, dating back 
to Millot 1 in 1773. Since his time it has been repeatedly advised ; for 

1 Taylor, op. cit. 



Methods for effecting 
gradual reduction. 



Methods for effecting 
rapid reduction. 



GRADUAL REDUCTION BY REPOSITOR. 



453 



example, by Colombat, Gross, Sims, Barnes, and others. Of the bene- 
fit of the first of these methods there is little doubt ; of that of the 
second there is none. 

Gradual Reduction by Repositor. — This method dates back to 
Von Siebold, 1 who employed a curved stem surmounted by a fine 



Fig. 231. 




Cup and Stem for making Continuous Pressure in Replacing the Inverted Uterus. 

sponge, the stem being held in situ by a T-bandage. After him it was 
repeatedly and successfully employed, and to-day it is coming again 
into favor, having been recommended by Drs. Hicks and Barnes of 
London. The former employs a solid stethoscope, the large extremity 
covered by India-rubber ; the latter, a hollow caoutchouc cup fixed to 
a curved stem. Both of these are supported by a T-bandage. 

Before the cup is adjusted a long compress, consisting of a bag of 
muslin stuffed loosely with cotton, should be placed across the hypo- 
gastrium, so as to extend from the anterior superior spinous process of 
one ilium to the other, and to lie just above the symphysis pubis. This 
should be fixed in position by a band of adhesive plaster made to 
encircle the body entirely. The compress, being about eight inches 
in circumference, forms a firm ridge across the pelvis and furnishes 
counter-pressure against the retreating uterus. The bands represented 
as attached to the stem of the instrument may consist of India-rubber 
tubing or of India-rubber elastic bands, by which gentle, steady, and 
gradually increasing pressure may be kept up. 

This constitutes one of the best, if not the very best, of all the 

1 Ch. F. AYeiss, Paris, op. tit. 



454 INVERSION OF THE UTERUS. 

means at our disposal for effecting gradual reduction of the inverted 
uterus. One point requires special attention : sometimes, when the 
vagina is abnormally voluminous, the uterus gets out of the line of 
pressure ; it bends upon itself above the edges of the cup, and not only 
does the pressure exerted accomplish no good ; it absolutely does harm, 
and creates the danger of inflammation of the tissue of the uterus. 
This should be prevented by tamponing around the cup, after it is 
adjusted, with carbolized cotton, as explained in connection with elas- 
tic pressure by the water-bag. 

The force exerted by the elastic bands should not be great, for we 
should look for the desired result not to great but to gradual and stead- 
ily sustained pressure. 

Elastic Pressure by Vaginal Water-bag. — The demonstration of the 
important fact — the most important, indeed, connected with this sub- 
ject — that elastic pressure was capable of greatly aiding reposition of 
an inverted uterus belongs to the late Dr. Tyler Smith. We say 
" greatly aiding," for he combined taxis with it. It was left for Bock- 
endahl of Germany to prove that it could effect reduction unaided. 
Smith's plan consists in passing the hand into the vagina night and 
morning, and kneading the uterus for ten minutes, and during all the 
intervening period keeping an air-pessary in the canal. Bockendahl 
simply trusts to elastic pressure alone, thus making an important 
improvement upon Smith's plan. 

The best method for employing elastic pressure we have found to be 
this : Pass a Sims speculum and tampon around the uterus firmly with 
carbolized cotton soaked in glycerin, so as to keep it from slipping out 
of the line of pressure. Then introduce an India-rubber bag and fill 
it with water. Cut a strip of adhesive plaster two and a half inches 
wide, and of sufficient length to extend from the lumbar region 
between the thighs of the patient and as high up as the navel. Two 
holes should be cut in it, one for the tube of the rubber bag to pass 
through, the other to leave the urethra free. After the bag is intro- 
duced into the vagina this strip of plaster is heated and attached to the 
surface. The bag may afterward be rendered more tense by pumping 
in water, or the amount of its contents may be diminished by turning 
the stopcock, which prevents its escape. While the method is in ope- 
ration the patient should be kept in bed and all pain quieted by the 
use of opium. The bladder should be emptied by the catheter, and 
the bowels, previously thoroughly evacuated, be kept constipated. 

A Stream of Cold Water. — This method has not been sufficiently 
tested to command confidence, but it is worthy of mention and con- 
sideration. Dr. Charles Martin l of France succeeded in effecting 
reduction in a case which proved rebellious to other means by this, 
which he tried in the following manner : He introduced the speculum 
around the inverted uterus twice a day, and threw upon the fundus, 
with force, by means of a syringe, a stream of cold water. Then fill- 
ing the speculum with cold water, he kept the uterus immersed for 
three or four minutes. 

There is no limit to the time during which efforts at gradual reduc- 

1 Gaz. des Hop., 1853. 



RAPID REDUCTION BY TAXIS. 455 

tion may be persevered in. Such a limit is established solely by the 
patient's tolerance of the method tried. In one of the cases mentioned 
elastic pressure was kept up for eighteen days with successful result. 
Sometimes, however, the patient cannot tolerate elastic pressure or that 
by a repositor, for symptoms of peritonitis result from their use. Then 
it is that anaesthesia and rapid reduction offer themselves as valuable 
resources. 

Rapid Reduction by the Old Methods of Taxis. — Taxis has been 
practised for the reduction of chronic inversion certainly since the 
beginning of this century, and perhaps before that time, in two entirely 
distinct methods. First, the manipulations of the operator are directed 
to the constricting cervix, in order to overcome resistance there and to 
return first the parts which last escaped. Second, these manipulations 
are directed to the body, in order to return first the parts which escaped 
first. The first of these methods is thus described by Capuron : 1 " If 
the orifice be not sufficiently dilated to allow the inverted portion to 
return easily, it is a better plan to take the tumor in the palm of the 
hand, with the fingers distributed around its pedicle, and to reduce first 
the portion which was inverted last, as if we were dealing with a her- 
nia." " We encounter at this point," says Aran, 2 " two opinions which 
have arisen in relation to the reduction of the uterus inverted during 
labor ; one party desiring to return first the parts which escaped last, 
subjecting the uterus to a general compression, so as to soften it to a 
certain extent and force it to pass the orifice little by little, com- 
mencing with the least voluminous parts Arrived at the tumor, 

if the operator wishes to employ the first method, he kneads it so as to 
soften it and cause it to pass more easily through the constricted orifice 
in which he engages his fingers." Becquerel 3 describes it thus : "It 
is advisable, as far as practicable, to return first the parts which last 
escaped ; for in this way we dilate in advance the muscular fibres which 

oppose reduction (P. Dubois Danyau) M. Velpeau considers this 

the best method." 

The second method of taxis consists not in manipulating the "con- 
stricted orifice in which he engages his fingers," so as to "dilate in 
advance the muscular fibres which oppose reduction," as Aran and 
Becquerel express it, but in dimpling or indenting the fundus itself, so 
as to make of the indented or invaginated portion a species of wedge 
which is forced into the cervical constriction. In recent cases of inver- 
sion, occurring, as the vast majority of these cases do, after labor, 350 
out of 400 reported by Crosse having done so, the centre of the fundus 
may be indented and carried up through the cervical canal ; and even 
in chronic cases such an invagination has been attempted. Our impres- 
sion is that the manipulations practised on the fundus in chronic cases 
act not in this way, but in overcoming cervical resistance, and thus 
accomplishing in a more indirect and imperfect way what the French 
method, styled the method of Viardel by Becquerel, does by engage- 
ment of the fingers within, and direct expansion of, the cervical con- 
striction. It is scarcely applicable to other than recent cases. 

1 Mai. des Femmes, 2d ed , p. 510. - Mai de /' Uterus p 901 

3 Mai de I 1 Uterus, tome 2, p. 314. 



456 INVERSION OF THE UTERUS. 

The diagnosis having been clearly made and reduction determined 
upon, the bowels and bladder should be emptied, and the patient put 
under the influence of an anaesthetic and laid on her back upon a strong 
table. The operator should always be attended by three or four reliable 
counsellors, upon whom he may call not only for advice, but physical 
aid. As the late Prof. Elliot has pointed out, the strength of one man 
will often fail to accomplish what that of several, replacing each other 
in rapid succession, will readily effect. Having thoroughly oiled one 
hand, the nails of which have been pared, the operator should slowly 
dilate the vagina so as to introduce it and grasp in its palm the entire 
tumor. The other hand should be laid upon the abdomen, so as to 
press just over the ring which marks the non-inverted cervix, and 
oppose the force exerted through the vagina, so as to prevent too great 
stretching of this canal. 

[In a case of four years' standing which I attended with Dr. Joseph 
Worster of this city, and which had been subjected to eight attempts pre- 
vious to my seeing it, each varying in duration from two to three hours, I 
suggested substituting for the hand a cone of boxwood four inches long. 
The patient being very thin, this could readily be inserted into the abdom- 
inal ring of the uterus, and it was gradually forced down into the inverted 
fundus for such a distance as to dilate the cervix and allow reposition. 
Since the experience gained in that case I have always employed this 
abdominal plug for counter-pressure, except in fat women ; and this course 
has likewise been adopted by Byrne and others. — T. Gr. T.] 

In attempting reduction by the hand in the vagina clasping the 
inverted uterus, the operator should not adhere too long to one plan of 
manipulation, but try, one after the other, the methods of manipulation 
which will now be mentioned : 

Emmet's Method. — This consists in giving to the finger encircling 
the cervix a decided motion of extension, while counter-pressure is 
actively kept up by the fingers over the abdominal ring, so as to 
expand this by the conjoined action of the two hands. We had sup- 
posed this method to be identical with that of Viardel, but its proposer 
declares it to be different from it in many essential respects, and speaks 
highly of its merits. A full exposition of it will be found in his work 
upon The Principles and Practice of Gynecology. 

Barrier 's Method consists in spreading the four fingers around the 
uterus, pressing the thumb against the fundus, and forcing the neck 
against the curve of the sacrum as a point of resistance. 

Noeggeratlis Method consists in placing the index finger upon one 
horn of the uterus, the thumb upon the other, and so compressing as 
to invert one or both cornua. Before rein version of the neck it should 
not be tried. For reducing the body after the neck has yielded it is a 
most valuable plan. [I have succeeded by it in 8 out of 5 cases which 
I have treated.— T. G. T.]. 

Courtys Method consists in passing the index and middle finger up 
the rectum, dipping them into the cervical ring, and thus gaining a 
point of resistance. It is one of the best at our command, and may be 
combined with Noeggerath's method — one being directed to reduction 
of the neck, the other to that of the body. 



METHODS OF REPLACING THE UTERUS. 



457 



Thomas's Method consists in abdominal section over the cervical 
ring, dilatation with a steel instrument made like a glove-stretcher, and 
reposition of the inverted uterus by any one of the methods mentioned, 
by the hand in the vagina. Fig. 232 will render this clear. 

This procedure, let it be remembered, is not offered as a method of 
treating inversion of the uterus, but as a substitute for amputation. 
Few cases will, we think, resist elastic pressure and judicious taxis, 
but that some will do so cannot be questioned. It is to save these few 
cases from amputation that abdominal section is suggested. 



Fro. 232. 




Replacement of Uterus by Dilatation through Abdominal Incision. 

One of the cases operated on in this way has proved fatal. Let it 
not be forgotten that a certain number of those cases treated by elastic 
pressure and by taxis likewise do so, for, as in my second case, these 
operations are often performed upon exsanguinated women whose blood 
is impoverished. One instance of death after reduction by elastic 
pressure is recorded by Lawson Tait in the eleventh volume of the 
London Obstetrical Transactions, while one of the earliest cases on 
record reduced by taxis, that of Dr. White of Buffalo, likewise ended 
fatally. 

Tates (Cincinnati) Method consists in introducing the index finger 
of one hand into the rectum, and that of the other into the bladder, and 
with both dilating the cervical ring, while the two thumbs in the vagina 
press the fundus upward. Theoretically, this method is exceedingly 
plausible, but we doubt whether both bladder and rectum may not be 
injured by the pressure. Tate reports a reduction by his method after 
forty years of inversion. 

If a case should prove rebellions to taxis repeatedly and intelligently 
applied, and to prolonged and powerful elastic pressure, what is" to be 
done? Only two courses have been open to us: one to leave the ease 
unrelieved, the other to perform amputation. In an elaborate report of 
cases of inversion given in the American Journal of Obstetrics for 



458 INVERSION OF THE UTERUS. 

August, 1868, the results in fifty-eight cases of amputation are given. 
By this statement it will be seen that nearly one- third of all operated 
upon died ; and let it not be forgotten that this number died, not in 
being cured, not in an effort, even, at attaining perfect health, but in 
an attempt at purchasing immunity from a series of dangerous and 
annoying symptoms at the price of that organ of which Hippocrates 
says, "Propter uterum est mulier." 

It is incumbent on us to state that this method has not received the 
endorsement of the profession. Appreciating this, we should have 
omitted it entirely from enumeration here did we not feel that in the 
future it will receive more favorable consideration and prove of real 
value. 

[In one case of puerperal inversion of several months' standing I felt 
justified in adopting eventually the last resort of amputation, after sev- 
eral prolonged attempts at manual reduction had been made by myself and 
others before me. The inverted organ had become so bruised and soft that 
I feared further manipulation would perforate it- Hence, I performed lapa- 
rotomy, and with two glove-stretchers attempted to dilate the cervical ring 
and effect reduction. But as soon as the stretchers were withdrawn the 
ring contracted so firmly that it was absolutely impossible to force the uterus 
through it. Finally, I passed a Peaslee needle through the abdominal wound 
and fundus into the vagina, attached a stout silk ligature armed with a thick 
rubber drainage-tube to it, withdrew the needle, and, using the ligature with 
the drainage-tube as a fulcrum on the fundus, attempted thus to draw the 
latter through the ring, which I kept dilated at the same time. But the 
bent drainage-tube tore through the macerated fundus, and nothing was left 
for me but to amputate the uterus. I removed the ovaries and tubes, closed 
the abdominal incision, and applied an elastic ligature about the uterus just 
below the extensor os. On the thirteenth day the uterus was found to have 
sloughed away, and the patient made an uninterrupted recovery. I do not 
recommend this procedure, but report the case merely to show what occa- 
sionally must be done from sheer necessity. — P. F. M.] 

The use of a repositor by which to make direct pressure and aid in 
reduction has been resorted to by Depaul and others. Prof. J. P. 
White has successfully employed one which by its simplicity and efficacy 
makes it worthy of especial mention. Fig. 233 shows this instrument, 
and likewise makes evident the method of reduction which the expe- 
rience of nine cases extending over a period of fifteen years has led him 
to adopt. 

Excellent repositors have likewise been invented by Aveling and 
Byrne. The latter of these is constructed upon the best mechanical 
principle which has ever been applied to this process, consisting of a 
cup which is made shallower and less capacious by the action of a screw 7 
at its lower extremit}^ as the inverted uterus gradually returns to its 
place. We have employed it w T ith perfect success in one case, and 
esteem it very highly. 

It impossible to set an absolute limit to the time which should be 
alloted to one attempt at immediate reduction, but these efforts cannot 
be persisted in much longer than one or tw T o hours without great danger 
of cellulitis or peritonitis. It is true that numbers of successful cases 



METHODS OF AMPUTATING. 



459 



are on record in which from three to five hours have been spent in 
continuous exertion before success was accomplished, and in which no 
unfavorable symptoms have arisen; but a safer and more judicious 
course would be to desist after a reasonable effort, secure what has been 
gained by placing a caoutchouc bag in the vagina or closing the os uteri 



Fig. 233. 




Rapid Reduction by White's Method. Operator grasps uterus, a, and presses his chest against 
spiral spring, g,f, which forces cup of repositor against fundus. 



by silver sutures as practised by Emmet, after the method shown in Fig. 
234, administer a large dose of opium, and make another attempt in 
thirty-six or forty-eight hours. Manipulation should then be cautiously 
repeated for about the same period, and again, in case of failure, fol- 
lowed by the air-bag or closure by suture. 

Methods of Amputating. — Although it cannot be denied that 
instances may present themselves in which, from impossibility of return- 
ing the inverted uterus, removal of the whole organ is indicated, it is 
equally undeniable that the operation has been resorted to very often 
upon insufficient grounds and before efforts at reduction had been fairly 
tried. Tyler Smith succeeded after persevering with elastic pressure for 
eight days, and Dr. F. A. Ramsay 1 of Knoxville, Tennessee, after 
seventeen or eighteen days of effort. Does any one doubt that in the 
hands of many less persevering practitioners both these cases would 
have been treated by amputation before success was attained ? Ampu- 
tation of the inverted uterus will surely be less frequently performed in 
the future than it has been in the past. It is destined to assume among 
operative procedures its proper place as a last resort. In addition to 
its own manifest and inherent dangers it must ever present these great 
objections : 



Tavli 



r, <>/>. c(/. 



460 



INVERSION OF THE UTERUS. 



1st. Hernia of the abdominal or pelvic viscera may have taken 
place into the inverted sac ; 

2d. It frequently produces emansio-mensium and its train of 
evils ; 

3d. It necessarily results in sterility. 



Fig. 234. 




kzie' 



Partly-restored Uterus sustained by Closure of Os Externum (Emmet). 



It is impossible to conceive of circumstances which would justify 
the procedure before full consultation with the most able counsel 
attainable. 

Removal of the uterus, although attended by great danger, often 
ends in recovery. This will not be wondered at when it is borne in 
mind that even tearing away of the organ has been several times 
recovered from. Radford, J. C. Clarke, 1 and others have reported 
cases in which an inverted uterus has sloughed off from strangulation 
without a fatal issue, and Osiander for many years showed a patient in 
his lecture-room from whom, after delivery, the midwife tore away not 
only the placenta, but the inverted uterus to which it was attached. 
A case of similar kind is recorded in the Gf-azette des Hopitaux for 
1842. One child being born, the midwife felt the breech of another, 
as she supposed. Around it she passed a handkerchief, pulled with 
all her force, and dragged away uterus and adnexa. The patient 
recovered ! 

A comprehensive view of the results of amputation is presented by 
Dr. West in the following table : 

1 Dublin Journal, 1837. 



METHODS OF AMPUTATING. 461 

Operation 
Recovered. Died, abandoned. 

Uterus removed by ligature 45 33 10 2 

" " " knife or ecraseur 5 3 2 

" " " knife or ecraseur, preceded by 

the ligature _9 _6 _3 

59 42 15 2 

Out of 58 cases of amputation collected in the report in the Ger- 
man journal recently alluded to, 18 were fatal — nearly one- third. 

Should it be deemed advisable to resort to this procedure in spite of 
the dangers incident to it, there are four methods by which it may be 
performed : the knife or scissors preceded by the ligature ; the ecra- 
seur, preceded by the ligature ; the elastic ligature ; and the galvano- 
cautery. 

Experience proves that removal of an inverted uterus by the knife, 
or even the £craseur, is likely to be followed by profuse and dangerous 
hemorrhage. To avoid this a method advised by Dr. McClintock of 
Dublin may be adopted. It consists in the application of a strong 
ligature for from two to three days before the operation. This oblite- 
rates the vessels, and just about the time that decomposition of the 
strangulated organ begins amputation is practised. Even should the 
galvano-cautery be resorted to, so great is the danger of immediate 
and remote hemorrhage that it is advisable to precede its use by that of 
the ligature for a few days. Courty strongly recommends ligature of the 
neck of the inverted organ by a rubber ligature, which he tightens on 
the second day as much as possible. The uterus is amputated by this 
on the twelfth or fourteenth day. During the use of all these meth- 
ods pain and nervous disturbance should be quieted by the hypoder- 
mic use of morphia, and septicaemia obviated by antiseptic vaginal 
injections. 

Hegar and Kaltenbach l recommend the following plan for amputa- 
tion : Sutures of metal or silk are passed through the cervix high up, 
and tightly drawn so as to constrict all vessels and completely close the 
peritoneal cavity. Then, by any means which the operator may select, 
the body of the uterus is amputated. By this procedure hemorrhage 
is kept under control, and the parts are so arranged as to favor subse- 
quent union. 

Removal of the uterus by ligature alone should never be attempted. 
Not only have Ave better and safer means ; statistics prove this to be an 
especially dangerous method. Out of 33 cases thus operated upon, 17, 
over half, ended fatally. [The elastic ligature seems to me bv fir the 
safest method.— P. F. M.] 

Resume of Plans of Treatment. — Let us suppose that a case of 
chronic inversion applies for treatment to a general practitioner ; what 
are the methods by which he could most easily and safely test the ques- 
tion of his ability to overcome the difficulty without resorting to the aid 
of a specialist ? We would advise the following course as having these 
advantages : it is often equal to the accomplishment of replacement : 
even when it does not prove so, it is safe ; and it does not ordinarily 

1 Hegor and Kaltenbach, Op, Gi/n., p. 279. 



462 INVERSION OF THE UTERUS. 

alienate the co-operation of the patient, as an injudicious course may 
very readily do by the discomfort which it induces : 

1st. The bowels should be thoroughly evacuated by a course of mild 
cathartics ; vaginal irritation and engorgement be relieved by copious 
hot vaginal injections; and uterine congestion, which always exists, be 
overcome by rest. 

2d. Pressure by the cup and stem should then be fully tried for a 
fortnight, hot vaginal injections and inunction of the cervix with bella- 
donna being employed at the same time. 

3d. Elastic pressure by vaginal water-bags should then be tried, the 
uterus being kept in the line of pressure by means of a tampon of anti- 
septic cotton saturated with glycerin. 

4th. Should this not produce good results in a week, and no untoward 
symptoms have developed, taxis should be tried for a short time once or 
twice a day. 

5th. Should success not now crown his efforts, the practitioner might 
try the use of a stream of cold water projected against the inverted 
fundus, or this might be combined with elastic pressure, taxis, and the 
other means just mentioned. 

All these means failing, resort to more radical, efficient, and hazard- 
ous ones will now become necessary. But let the practitioner remember 
that so long as the temperature and pulse remain normal or nearly so, 
and there is absence of severe pain, he may with safety persist in the 
mild efforts at reduction which have been mentioned, even for several 
weeks. Should every general practitioner do this systematically and 
intelligently, few, very few, cases of this accident would fall into the 
hands of the specialist, and a great deal of fame now concentrated upon 
a few would be distributed among many. 

The day for rapid and brilliant replacements of the uterus in condi- 
tion of chronic inversion has passed and gone. There are unquestion- 
ably cases which may call for immediate or at least for rapid replace- 
ment, and others which will demand the most heroic resources of surgery, 
from the fact that all milder ones have failed. But the rule should, with 
our present light upon the subject, be positively and unhesitatingly 
accepted that gentle, slow, and safe methods should always take pre- 
cedence over rapid, harsh, and dangerous ones. As a very general 
rule, time is here a matter of no moment. Certainty of result and 
freedom from danger are the great desiderata. A case of chronic inver- 
sion presenting itself under the circumstances which are ordinarily 
attendant upon the condition, the surgeon who selects the plan of rapid 
over that of gradual reduction is exposing his patient to risks which 
might have been avoided in the attainment of a result which would 
have been as likely under the safe as under the dangerous course. If 
all goes well after adoption of the latter, neither surgeon nor patient 
will question the wisdom of the choice ; but supposing that a fatal issue 
occurs ! 

It must be appreciated that we do not undervalue the serious pro- 
cedures which have been recommended and practised for obstinate cases 
of inversion. We would unhesitatingly resort to them after failure with 
safer and less efficient procedures. It is a resort to them as a matter 



PARA-UTERINE CELLULITIS. 463 

of election, and before the milder means have been tried, that we 
deprecate — a willingness to weigh the safety and interests of the patient 
against any other consideration that we condemn. 

As one looks back upon his experience in surgery he can see many 
cases which, if he could have availed himself in them of knowledge 
which did not exist a few years ago, would in all probability have had 
a favorable instead of a fatal result, and he feels regret. If he have at 
his disposal resources which could have produced such a happy change 
in the record, and which he from choice did not use, regret is apt, in 
the mind of a conscientious man, to merge painfully into remorse. 

Hernia of the Uterus — Hysterocele. 

In order to complete the subject of displacements of the uterus we 
will mention a very rare form — namely, that where the uterus is found 
in the sac of an inguinal or crural hernia. Cases of this kind have 
been reported by Olshausen, Leopold, Rectorzik, Winckel, and Scan- 
zoni. 1 In the two latter pregnancy up to the fourth month complicated 
the case. 

The uterus may enter the hernial sac either in consequence of trac- 
tion by the adherent intestine or omentum, or because in large crural 
herniae the peritoneum of the corresponding broad ligament forms a 
part of the hernial sac and draws the uterus after it. 

The diagnosis is usually not difficult, because the uterus is found 
absent from its normal position and the contents of the hernial sac are 
larger than is generally the case. If the uterus should be gravid, its 
increasing size will naturally help to make the diagnosis. 

Treatment. — Of course as soon as the diagnosis is made, reposition 
of the contents of the hernial sac is indicated. This should be per- 
formed in the usual manner, if possible. If pregnancy is present, 
abortion per vias naturales should be induced, or if irreducible 
Cesarean section, perhaps even removal of the whole organ after 
Porro's method, may be called for. Winckel operated in this man- 
ner, and fastened the stump in the abdominal incision. His patient 
recovered. 



CHAPTER XXXII. 
PARA -UTERINE CELLULITIS. 

History. — The history of this affection presents one of those exam- 
ples which are often repeated in medical literature, of a subject which 
was once understood being subsequently completely overlooked and 
forgotten. 

There can be little doubt that it is to this disease that allusion was 
made by Archigenes, who flourished in the second century, and whose 

1 I saw this case, and myself induced and completed the artificial abortion.— P. F. M. 
See Scanzoni's Beitriu/e, 1867. 



464 PARA-UTERINE CELLULITIS. 

account of it was subsequently repeated by Oribasius in the fourth and 
Aetius and Paul of iEgiua in the sixth and seventh. The last two 
unquestionably refer to it under the head of " Abscess of the Womb," 
for in one passage Paulus especially speaks of cases in which the 
" aposteme is seated about the mouth of the uterus." 
The modern history of the subject may be thus stated: 

Described by Richard Wiseman, 1 England, as "distempers of the uterus 

in childbed" : 1679 

Xichs. Puzos, 2 France, as " depots laiteux " 1743 

Bourdon, a pupil of Recamier, as " fluctuating tumor of 

true pelvis" 1841 

" Doherty, Ireland, as "chronic inflammation of the append- 
ages of uterus" 1843 

Marchal de Calvi, as " intra-pelvic phlegmonous abscess" . 1844 
" Churchill, 3 Ireland, as "abscess of uterine appendages" . 1844 
" Levei-, England 1844 

It will thus be seen that after being appreciated, then entirely for- 
gotten, then for a second time brought into notice, the knowledge of 
this affection languished for nearly two centuries, to be suddenly 
restored by the efforts of four investigators who entered the field 
almost simultaneously. It would be unjust to a conscientious observer, 
M. Auguste Nonat, not to mention the great influence which his wri- 
tings have had in advancing our knowledge ; but when he commenced 
his investigations in Hopital Cochin in 1846 the morbid state which he 
subsequently did so much to elucidate had already received consider- 
able attention in Great Britain. 

Definition, Synonyms, and Frequency. — This disease, which is now 
known to be of frequent occurrence, consists in an inflammation of the 
adipose and areolar tissue lying behind, in front of, and at the sides of 
the uterus, and extending up between the layers of serous membrane 
which make the broad ligaments. It has been described by different 
writers under the following titles : parametritis, peri-uterine phlegmon, 
inflammation of the broad ligaments, pelvic abscess, and pelvic cellu- 
litis. The last term, which was applied to it by Sir James Simpson, 
indicates the nature and seat of the disease, but it is open to the grave 
objection of being too general in its application, and not sufficiently 
confining within proper limits a distinct and well-defined affection. 

Anatomy. — "The subperitoneal pelvic tissue," says Dr. Savage, 4 in 
his work on the Female Pelvic Organs, "fills up all that part of the 
pelvic cavity between the pelvic 'roof and floor of the pelvis which is 
not. occupied by the viscera, and is the sole bond of union between 
them." Any one can satisfy himself as to the abundance of loose 
cellular tissue in the pelvis by even a rough dissection. It will be 
found in the broad ligaments in great abundance, separating their con- 
tents, between the vagina and rectum, the rectum and sacrum, the 
uterus and bladder, the bladder and abdominal parietes, and investing 
the psoas and iliac muscles. The relations of the urethra and rectum 

1 McC'lintock, Diseases of Women, p. 1. 

2 Drs. West and McClintock date the appearance of Puzos' Traite d' Accouchement, 
1759. They are probably in error, as Bernutz and Nonat both date it 1743. 

3 West, Diseases of Women, Am. ed., p. 310. 4 Savage, op. cit. 



PATHOLOGY. 465 

to this tissue are peculiar, each being isolated in a sheath or canal 
which may be removed with ease. 

Everywhere around the pelvic organs cellular tissue exists except 
between the peritoneum and uterus. Here so little is discoverable that 
some have ventured to deny its existence, while all admit that over the 
body of that organ it is difficult of demonstration. Dr. Farre l declares 
that along the median line and over the whole fundus he has found the 
peritoneum inseparable from the uterus, except after prolonged mace- 
ration. On the sides of the organ and at the cervix the connection is 
not so intimate, loose cellular tissue existing at these points to such an 
extent as to permit of the investing membrane gliding upon the uterus. 
M. Goupil, 2 who has made a special study of this tissue, declares that 
it is so small in amount at the point of contact of the peritoneum and 
vagina and in front and rear of the uterus that " its presence can 
scarcely be determined." 

Pathology. — According to the wide range given to the affection by 
the majority of English pathologists, this areolar tissue is the seat of 
the disease under consideration, which may affect any or all of its 
parts. Drs. West, Simpson, and most British writers, except Dr. 
Bennet, adopt this view, and regard as instances of the affection any 
inflammation of the cellular tissue within the pelvis. But this evi- 
dently leads to great confusipn. It is certainly not conducive to clear- 
ness of comprehension to blend the description of iliac, psoas, and peri- 
rectal abscesses with this disease. 

French writers, 3 on the contrary, regard as instances of peri-uterine 
cellulitis only inflammation of the cellular tissue of the broad ligaments 
and of that immediately in contact with the uterus at its junction with 
the vagina and bladder. While admitting that inflammation originating 
here may spread, by continuity of structure, to other areolar tracts in 
the pelvis, they regard these as complications, designating them by dif- 
ferent appellations, and do not admit them as elements of this affection. 
This is the definition which we would adopt, and to express it clearly 
have employed the term peri-uterine, in place of pelvic, cellulitis. 

Para-uterine cellulitis has three stages : 1st, the stage of active con- 
gestion ; 2d, that of effusion of liquor sanguinis ; 3d, that of suppu- 
ration. In its course it may be likened to an ordinary furuncle : at 
first there is simple congestion accompanied by pain, heat, and swell- 
ing ; then liquor sanguinis is effused, which creates hardness and ten- 
sion, and lastly suppuration occurs and ends the morbid process, unless 
one of two other terminations takes place. Resolution may occur, or, 
in place of suppuration, the areolar tissue involved may be destroyed, 
as it so generally is in anthrax and phlegmonous erysipelas, and come 
forth as a sloughing mass. 

The term " phlegmon, " now almost obsolete with us, but still in use 
on the continent of Europe, signifying inflammation of areolar tissue, 
is strictly applicable to this affection. Its source is similar to that of 
areolar inflammations in other parts of the body, and its three stages 
are identical with theirs. 

1 Cijc. Anat. and Phys. } Sup., p. 631, '-' Becquerel, p. 441. vol. i. 

3 Aran, Mai. de /' Uterus, p. 675, 



466 PARA-UTERINE CELLULITIS. 

The most common seat of para-uterine cellulitis is the areolar tissue 
of the broad ligaments, and generally that of one side only is affected. 

In a certain number of cases, where no affection of the areolar tis- 
sue of the broad ligaments exists, circumscribed tumors in immediate 
contact Avith the womb have long been noticed. Lisfranc supposed 
them to be due to partial parenchymatous metritis, "engorgements," 
which had resulted in enlargements of one part of the organ ; and no 
one contradicted him until Nonat 1 about the year 1849 described 
them as being due to phlegmonous inflammation in the areolar tissue 
immediately around the uterus — i. e. between the cervix and rectum, 
the cervix and bladder, and immediately by the side of the neck. The 
existence of this variety of cellulitis has been denied by Bernutz, 
who sustains his position by abundant argument. In reference to it 
we will merely say here that there are, so far as our knowledge extends, 
only two cases of such limited cellulitis substantiated by autopsic evi- 
dence — one reported by Demarquay, 2 the other by Simon. 3 Never- 
theless, judging from clinical observation, one is inclined to side 
with the view of Nonat rather than with that of Bernutz. There are 
many cases in which abscesses in the broad ligaments point and dis- 
charge anteriorly or posteriorly to the cervix, but these come within a 
different category. The broad ligaments and their entire contents, 
cellular tissue, ovaries, and Fallopian tubes, are more frequently affected 
than any other parts, and Aran goes so far as to say that the col- 
lections of pus occurring in para-uterine cellulitis "belong more par- 
ticularly to the ovaries and tubes." In post-mortem examinations 
these parts are often found imbedded in a mass of effused material, the 
ovaries, one or both, in a state of suppuration, and the tubes inflamed 
and filled with pus, or constricted at both uterine and ovarian extrem- 
ities and dilated with sero-purulent material so as to constitute tubal 
dropsy. We have examined the post-mortem reports of cases by a 
number of authorities with reference to this point, and, rejecting only 
those in which the examination was made in too careless a manner to 
allow of their admission, we present them in the following table : 

Seat of Purulent Collection. 

Behind the uterus connecting with suppurating 
cyst in left ovary; small abscess in right 
ovary. 

Behind uterus and rectum extending into broad 
ligaments of both sides. 

On left side extending from uterus to ilium. 

Behind uterus and vagina, extending into left 
broad ligament ; another the size of a hen's 
egg just behind the uterus, opening into a 
third, very large, extending to sigmoid flex- 
ure and into broad ligament. 

Left broad ligament. 

Opposite right sacro-iliac synchondrosis under 
psoas muscle ; another to the left of and behind 
the rectum. 

Left broad ligament. 

Left broad ligament. 

1 Op. tit, p. 237. 2 Gazette des Hopitaux, April 17, 1858. 

3 Bull, de la Soc. Anat. de Paris. 



. of Case. 


Authority. 


1. 


M. Nonat. 


2. 


M. Nonat. 


3. 
4. 


M. Nonat. 
M. Nonat. 


5. 

6. 


Dr. West. 
Dr. West. 


7. 
8. 


Dr. West. 

Dr. McClintock. 



PATHOLOGY. 467 

No. of Case. Authority. Peat of Purulent Collection. 

9. Dr. Demarquay. In cellular tissue between uterus and rectum, and 

also in recto-uterine pouch of peritoneum. 

10. M. Simon. Size of a small orange, between the bladder and 

uterus, sending conoidal prolongation into left 
broad ligament. Its limits were as follows : 
base of bladder in front ; neck and body of 
uterus behind ; peritoneum above ; vagina 
below ; at the sides it ran off into the broad 
ligaments. 

11. M. Aran. Left broad ligament. 

12. M. Aran. Left ovary, right tube, with pelvic adhesions 

throughout. 

13. M. Bourdon. Size of an apple in left broad ligament. 

14. M. Aran. At side of uterus and in the left broad ligament. 

It will thus be seen that of this number, which is large when it is 
remembered that the disease rarely ends in death, but two cases present 
instances of inflammation of the cellular tissue uncomplicated by dis- 
ease of the ovaries or tubes or of the broad ligaments. One of these, 
that of Simon, is conclusive of the possibility of such disease ; that of 
Demarquay is doubtful, for with the abscess in the cellular tissue there 
Was also one in the cul-de-sac of Douglas. 

The autopsies in the above collection show that there is a very 
common and complicating connection between inflammation of the pel- 
vic cellular tissue and inflammatory disease with or without accumula- 
tion of pus in the ovaries, Fallopian tubes, and pelvic peritoneum. In 
former days the exact relation between these several conditions was not 
properly understood, and it was supposed that the purulent collections 
in the ovaries, Fallopian tubes,, and peritoneum were the results of the 
same process in the cellular tissue of the pelvic cavity. Ovarian 
abscess, pyo-salpinx, and intra-peritoneal abscess were therefore 
assumed to be simple complications or consequences of pelvic cellu- 
litis. This is, however, by no means the case, as shown by the inves- 
tigations of recent days, chiefly as a result of our more correct insight 
into these affections following the frequency of abdominal section. 

It has become fashionable of late for many of our most enthusiastic 
and progressive laparotomists to deny utterly the existence of such a 
pathological condition as pelvic cellulitis, except in a few rare instances 
after parturition, and to assume that all cases of inflammatory exuda- 
tions in the pelvis, with or without suppuration, are unquestionably 
intra-peritoneal ; that is to say, that all cases of pelvic inflammation 
proceed primarily from the Fallopian tubes, and involve secondarily 
the ovary and the adjacent peritoneum. Pelvic abscess, as such, 
exists in the minds of these gentlemen only as a synonym for abscess 
in the Fallopian tube (pyo-salpinx), ovary, or pelvic peritoneum, any 
one of which may, by adhesion and perforation, force its way into the 
pelvic cellular tissue, and thus simulate an abscess resulting from pel- 
vic cellulitis. We would thus find the tables turned upon the old 
assumption that inflammatory disease of the intra-peritoneal organs 
adjoining the uterus is the result of inflammatory action in the pelvic 
cellular tissue. Manifestly, neither view can be correct. In our opin- 
ion, inflammation of the pelvic cellular tissue, with its resultant conse- 
quences of dislocation of the uterus, pelvic abscess, and cicatricial indu- 



468 



PARA - UTERINE CELL U LITIS. 



ration, occurs independently by itself, as well as inflammation of the 
Fallopian tube, ovary, or adjacent peritoneum, with resultant purulent 
accumulations in these organs. It is true, a purulent deposit outside of 
the peritoneum may perforate into that cavity, and the reverse — prob- 



Fig. 235. 




Cross-section of the Pelvis, showing the Peritoneal and Subperitoneal Cavities (Luschka) 



ably more frequently the latter — and both may exist together at the 
same time in one and the same individual, or a pyo-salpinx may rup- 
ture between the layers of the broad ligament. But that is no reason 
why they do not frequently occur separately and independently. Pel- 
vic peritonitis and pelvic cellulitis are, in fact, independent and entirely 
unassociated diseases, just as pleurisy of one part of the lung may occur 
at the same time with an inflammation of the substance of the lung at 
another point. 

In our opinion it is decidedly wrong and uncalled for to practically 
deny the occurrence of pelvic cellulitis. There is no reason why the 
cellular tissue of the pelvis should be free from the tendency to inflam- 
matory exudation undeniably accorded to the same tissue in every other 
portion of the body. In the table above cited it seems to us, from our 
present enlightened standpoint, that the cases in which the uterine 
appendages were found diseased were probably instances of primary 
disease of those organs, and only those in which the peritoneal cavity 
was found intact can be counted as true cases of cellulitis. 

Complications. — The complications of para-uterine cellulitis are — 
Endometritis ; 



COMPLICATIONS. 469 

Metrorrhagia ; 
Cystitis ; 

Uterine displacement. 
And as coincidences depending upon the same primary causes — 
Oophoritis ; 
Salpingitis ; 
Pelvic peritonitis. 
The occurrence of these complications with cellulitis is so frequent 
that they may almost be regarded as elements of it when it exists in 
severity. 

Endometritis, metrorrhagia, and cystitis are natural results produced 
by the general pelvic hyperemia which would of course be present 
under the circumstances. We have frequently seen cases in which the 
muco-purulent and bloody discharge from the vagina and painful mic- 
turition formed the salient symptoms complained of by the patient. 
Only the vaginal examination revealed the origin of these symptoms 
and the true nature of the case. As concomitants depending more or 
less upon the causes which produced the inflammation of the pelvic 
cellular tissue, we have the sympathetic inflammations of the ovaries, 
tubes, and pelvic peritoneum. The displacement of the uterus is of 
course produced by the pressure of the cellular exudation in the pelvic 
tissue. 

Course, Duration, and Termination. — It is necessary that we should 
here inform the reader that the account which we shall give of this part 
of our subject will differ essentially from that generally found in syste- 
matic works, for the reason that, regarding pelvic cellulitis and pelvic 
peritonitis, which are usually treated of synonymously, as different affec- 
tions, we shall attempt to describe them separately. Cellulitis proper — 
that is, uncomplicated by other diseases — rarely passes into a chronic 
state, but usually in the course of two or three weeks passes off by 
resolution or ends in suppuration, the former being much the more 
frequent termination. Any one of its usual complications, however — 
peritonitis, endometritis, ovaritis, or salpingitis — may become chronic, 
and thus leave the impression upon the mind of the observer that the 
original affection has done so. Or one or more abscesses may discharge 
themselves by long sinuses which fail to allow of their complete evacu- 
ation, and may continue to pour out pus for months or even years. In 
saying that cellulitis rarely becomes chronic, we look upon chronic pel- 
vic abscess rather as one of its results than one of its stages. If the 
case be of acute character and occur as a sequel of parturition, suppu- 
ration may take place in a few days, but ordinarily, even under these 
circumstances, it does not occur for two or three Aveeks. In a chronic 
case the effused matter may remain hard, resisting, and ligneous for 
months without showing signs of softening, but such instances are 
exceptions to the rule. After suppuration has occurred the disease 
may follow one of three courses : 

1st. The accumulated pus may discharge itself, and the abscess 
gradually dry up and disappear. 

2d. The empty sac, lined by pyogenic membrane, may for an unlim- 
ited time go on pouring out pus. 



470 PARA-UTERINE CELLULITIS. 

3d. Small abscesses may form and discharge in one part, then others 
may do so in another, until the whole pelvic areolar tissue is perforated 
by them and by fistulous tracts connecting them. 

There are various outlets for the imprisoned purulent accumulation : 

1st. Through the abdominal walls or saphenous openings ; 

2d. Through the pelvic viscera, bladder, rectum, vagina, ure- 
thra, or uterus. 

3d. Through the floor of the pelvis near the anus ; 

4th. Through the pelvic foramina, obturator, or sacro-ischiatic ; 

5th. Through the pelvic roof into the peritoneal cavity. 
Sometimes the purulent collection burrows into the surrounding tis- 
sues and evacuates itself at a distance. [In one case which I saw with 
Dr. Echeverria it passed through the sciatic foramen, and, burrowing 
upward and forward, came forth near the great trochanter. — T. G. T.] 
It may thus take so eccentric a course as to mislead the practitioner as 
to the seat of the abscess. 

The most frequent channels of evacuation are the vagina and rectum 
in the non-puerperal form, and probably the abdominal walls in the puer- 
peral, or at least the results of Dr. McClintock's 1 carefully-noted cases 
would lead us to believe so. In 37 puerperal cases treated by him 
which ended in suppuration, 20 abscesses discharged in the iliac regions, 
2 above the'pubes, 1 in the inguinal region, and 1 beside the anus. Of 
the remaining 13, 6 were discharged per vaginam, 5 per anum, and 2 
burst into the bladder. In the non-puerperal variety it is extremely 
rare for the abscess to discharge externally, and fortunately in both 
forms it is rare for it to burst into the perineum. 

Prognosis. — A guarded prognosis should always be made as to the 
time of recovery, for no amount of experience can foresee the course of 
the affection — whether the effused liquor sanguinis will disappear by 
absorption in three weeks, whether the discharge of one abscess will 
end the patient's suffering, or whether a chronic induration will exist 
for a great length of time. But, fortunately, it may be stated that the 
prospects as to life are decidedly favorable, though in cases occurring 
just after parturition there is always some danger from general peri- 
tonitis. 

Causes. — The disease usually occurs as a result of one of the follow- 
ing causes : 

Parturition or abortion ; 

Inflammation of uterus or ovaries ; 

Direct injury from coition, caustics, pessaries, operations, or blows. 
Parturition or abortion produces, according to statistics, from one- 
half to two-thirds of all the cases. Even this large proportion we 
believe to fall short of the truth, from the fact that those collecting the 
statistics from which the deductions were drawn made no distinction 
between this disease and pelvic peritonitis. Cellulitis will very rarely 
be met with, except after the parturient process. It is true that when 
the puerperal state exists as a predisposing cause exposure to cold, 
fatigue, over-exertion, etc. will excite it ; but under these circumstances 
they are merely immediate and exciting influences. 

1 Op. cit. 



SYMPTOMS. All 

If the uterus, ovaries, or any part of the pelvic organs are in a 
condition of acute or subacute inflammation, or if an increased vascu- 
lar engorgement of the pelvis exists, as is the case in impending or 
present menstruation, naturally the influence of a sudden exciting 
cause may produce a fresh inflammation of any one of the organs 
involved more readily than if the parts were in a quiescent state. 
Hence temporary hyperemia of the uterus, ovaries, tubes, pelvic cellu- 
lar tissue, or peritoneum offers an unusually favorable time for the exci- 
tation of a fresh inflammation of these organs, but it cannot be said 
that acute inflammation of the uterus, ovaries, or tubes in itself offers 
any special inducement for the production of an acute cellulitis. Again, 
pelvic cellulitis may exist, as already stated, entirely independently of 
inflammatory disease of the uterus or its appendages. Any chronic or 
acute disease of either the uterine parenchyma or mucous lining may, 
however, result in it, and we have more than once seen it follow appli- 
cations of mild character to the cavity of the uterus. 

Direct injury is by no means a rare cause in non-puerperal cases, 
though it generally proves active in those suffering from previous 
uterine or ovarian disorders. Thus it may follow operations upon the 
neck or body of the uterus — slitting the neck for flexion or contraction, 
for example — or simple dilatation by a tent. It may result from efforts 
at removal of intra-uterine growths, and one fatal case that we have 
met followed the ligation of hemorrhoids. 

As a rule, irritations inflicted upon the uterus below the internal os 
will result in pelvic cellulitis ; above that point, in pelvic peritonitis. 
The statement of the late Matthews Duncan that cellulitis is usually not 
idiopathic, but symptomatic of uterine or ovarian inflammation, is not 
borne out by recent observation, except on the general principle that 
all pelvic congestion predisposes to inflammation of one or the other of 
the organs situated in that cavity. 

Symptoms. — The acute form, and more especially that occurring 
after parturition, is usually ushered in by very decided symptoms, of 
which the most constant are the following : 
Chill ; 

Increased thermometric range ; 
Pain ; 
Fever ; 
Dysuria ; 
Metrorrhagia. 
The chill, though sometimes absent, is a very general symptom. No 
sooner does it pass off than the pulse rises to 110 or 120, increased 
heat is felt in the hypogastric region, and pain, which for a number of 
hours or perhaps days before was just perceptible, comes on with con- 
siderable violence. The thermometer shows marked increase of animal 
heat, the mercury rising to 103° or 104°, and in severe cases even 
higher. With these general symptoms there will be others pointing to 
the rectum and bladder, and should the affection exist in a menstruating 
woman the flow may be much increased. Even when the patient is not 
menstruating, uterine hemorrhage sometimes, though not frequently, 
comes on. 



472 PARA-UTERINE CELLULITIS. 

But he who awaits these symptoms for diagnosis will be led into 
man)- errors of omission, for subacute cases very generally, and acute 
cases sometimes, fully develop themselves without them. 

All cases may be brought under three heads as to severity of symp- 
toms : 

1st. Cases accompanied by chill, fever, pain, and ordinary signs of 
inflammation ; 

2d. Those accompanied by pain without chill or fever ; 

3d. Those marked by scarcely any symptoms except extreme feeble- 
ness and some sense of pulsation and weight about the pelvis, with 
hectic fever toward evening. 

Cases which have assumed the chronic form will present themselves 
with such a history as this : A patient who was delivered one, two, or 
three months ago has not recovered her strength, but is very feeble, 
has no appetite, and feels nervous, depressed, and feverish toward even- 
ing. She has no absolute pain, but fears that something is wrong 
about the womb, for now and then she feels a sensation of throbbing, 
tension, and weight about that organ, which is increased by defecation, 
urination, and walking. This prompts to physical exploration, which 
establishes the diagnosis. 

Physical Signs. — Physical exploration is the means on which we 
must rely for a rapid and certain determination of the character of 
these cases. Should the finger be introduced into the vagina during 
the first stage, the parts will be found to be very warm, and perhaps a 
swollen and cedematous spot may be detected. Upon pressing in dif- 
ferent directions great sensitiveness will be observed, and by conjoined 
manipulation a particularly sensitive point will be detected, usually on 
one side of the uterus. 

As the second stage, or stage of effusion, advances, induration occurs 
in the areolar tissue affected, and then, by careful vaginal touch com- 
bined with external manipulation, a tumor as large as a walnut, a goose's 
egg, or an orange may be detected in one of the broad ligaments or in 
the tissue around the cervix. 

But the examiner must not suppose that the mere introduction of 
the finger into the vagina will accomplish a discovery which often re- 
quires the greatest care and most thoughtful attention in examination. 
The finger )}eing passed up to the cervix, and the other hand placed 
upon the hypogastrium so as to make counter-pressure, it should be 
carefully pressed against Douglas's cul-de-sac and all around the cervix 
over the base of the bladder and as far as possible toward the fundus. 
Then it should be made in a similarly careful manner to traverse the 
sides of the pelvis where the broad ligaments are placed, and, last of. 
all, those parts below the pelvic roof. For one sufficiently practised in 
this kind of examination this procedure will generally be sufficient to 
determine the existence of even a very small point of induration on the 
sides or in front of the uterus. Sometimes, where it is posterior to 
that organ, a rectal exploration will throw much additional light upon 
the case. 

Should the disease have advanced to its third stage, in addition to 
the signs already noted, the uterus, which, as already mentioned, is gen- 



PLATE T 




Plate showing the Topographical Relations of the Pelvic Peritoneum and Cellular 
Tissue, and of their Respective Exudations. 

'Fig. 1. Pelvic Cellulitis.— Vertical section of pelvic organs, showing (e) exudation in the 
cellular tissue before and behind the uterus and in the anterior abdominal wall (pelvic 
cellulitis) ; a-b shows plane of transverse section of Figs. 3, 4, and 5. 

Fig. 2. Pelvic Peritonitis.— Vertical section, showing (e) exudation in Douglas*s pouch, sep- 
arated from healthy peritoneal cavity by adhesions (pelvic peritonitis). 

Fig. 3. Transverse Section through Normal Pelvis.— h, uterus ; r, rectum : b, bladder . 
u r, utero-rectal ligaments; r I, round ligaments; b I, broad ligaments. Light spaces show 
sections of peritoneal pouches. 

Fu;. 4. Pelvic Cellulitis.— The same, with a small exudation (<•) to left of broad ligament. 

Fig. 5. Pelvic Cellulitis. — The same, with large exudation (e) in right broad ligament, 
extending into the cellular tissue of the anterior abdominal wall and distorting the pel- 
vic peritoneal pouches. 

(Reduced from Fritsch's Clinical Plates.) 



DIFFERENTIATION. 473 

erally displaced, is now pushed from its normal position in a direction 
opposite to the accumulated pus. Sometimes it lies upon the floor of 
the pelvis, at others it is in a state of anteversion, retroversion, or 
latero-version, and, more rarely, sharply flexed, the body having 
remained movable after the cervix has become fixed. Into whatever 
malposition it has been forced, it remains to a certain extent immovable 
from fixation by adhesive lymph. 

Some authors claim that the fixation is by no means so complete or 
so universal as in pelvic peritonitis. We are of different opinion, hav- 
ing usually found the uterus absolutely immovable when encased in 
pelvic cellular exudations. Nonat declares that he has found the 
phlegmonous mass itself movable, but we are absolutely sure that he 
has mistaken an intra-peritoneal exudation, or rather a matting together 
of the inflamed ovary and tube, for a pelvic cellulitis. We personally 
have never seen an instance in which the exudation in pelvic cellulitis 
was not immovably fixed. 

Differentiation. — We may as well begin this section by the general 
statement that wherever there is cellular tissue in the pelvis there a 
pelvic cellulitis and a resultant exudation may be found. This remark 
applies to inflammations and exudations extending from the perineum 
to the iliac fossa and perirenal region behind and on either side, and to 
the umbilical region on the anterior abdominal wall. We have seen 
retro-peritoneal, and therefore cellular, exudations reach to these several 
points in a number of instances. Where the limit of the cellular tis- 
sue is reached and the region of the peritoneum begins, pelvic cellulitis 
is no longer found and pelvic peritonitis begins its sway. 

The diseases with which it may confounded are — 
Pelvic peritonitis ; 
Hematocele ; 
Fibrous tumors ; 
Retro-peritoneal carcinoma. 

Fibrous tumors are painless, free from tenderness, and movable in 
the pelvis. They are unaccompanied by chill, fever, and other signs 
of inflammation, and are closely attached to the uterus, so as to form 
part of it. The tumors resulting from cellulitis are the contrary of all 
this, and appear firmly attached, like bony growths, to the walls of 
the pelvis. 

Hematocele occurs suddenly with uterine hemorrhage, and is marked 
by prostration, coldness, and other symptoms of loss of blood. The 
tumor created is soft in the beginning and grows hard ; that of cellu- 
litis is hard in the beginning and tends to softening. 

Pelvic peritonitis shows the ordinary signs of peritoneal inflamma- 
tion, great tendency to relapse at menstrual periods, excessive pain and 
tenderness, and produces no distinct tumor in the beginning, but harden- 
ing of the whole pelvic roof. Later, a small tumor may be discovered, 
but it is usually posterior to the uterus and not on one side of it. The 
uterus is rather more movable than in cellulitis, especially from above 
downward, and when the body is fixed the cervix sometimes moves 
under pressure. 

Consequences of Cellulitis. — Neither the immediate nor the remote 



474 PARA-UTERINE CELLULITIS. 

results of this affection are so grave as those following pelvic peritonitis. 
The ovaries are seldom involved directly, and the same applies to the 
Fallopian tubes. It is only when peritonitis supervenes that these 
organs suffer. The uterus is seldom displaced sufficiently to produce 
permanent inconvenience ; in fact, except when diffuse suppuration 
with resultant constitutional disturbance and local cicatricial contrac- 
tions ensue, pelvic cellulitis generally terminates in a complete, restora- 
tion to health. Therefore, sterility, amenorrhoea, dysmenorrhoea, mon- 
orrhagia, tubal dropsy, and displacement seldom remain to attest the 
apparent gravity of the original disease. In this respect pelvic cellu- 
litis differs most agreeably from its twin sister, pelvic peritonitis. 

Treatment. — Should the practitioner be called in the acute stage of 
cellulitis, the patient should be at once completely quieted by opium. 
If pain be violent, the hypodermic method should be employed in its 
administration ; if not, it should be given by mouth or rectum. This 
drug throughout the acute stage of the affection should be steadily 
kept up. It accomplishes these results : it relieves pain, diminishes 
the severity of the inflammatory process, keeps the bowels constipated, 
produces sleep, and creates general nervous quietude. If when first 
seen the patient be suffering very severely, ten drops of Magendie's 
solution of morphia may be given hypodermically. 

Absolute rest should be enjoined, the patient not being allowed to 
sit up in bed for a moment upon any pretext whatever. Were we lim- 
ited to one remedial resource in this affection, Ave should choose rest in 
preference to all others, but to accomplish anything it must be abso- 
lutely enforced. 

The diet of the patient should be mild and unstimulating, consist- 
ing of milk with farinaceous substances and tea or coffee. 

If the case be seen very early, before the stage of effusion has 
occurred, a bladder of crushed ice should be laid over the hypogas- 
trinm in the hope of arresting the advance of the disease. But if the 
disease has advanced beyond the point where this seems possible, warm 
poultices of powdered linseed should be applied every third or fourth 
hour over the h} T pogastrium, the bowels be kept regular by mild laxa- 
tives and enemas, and febrile action, should it exist, be quieted by 
refrigerants and antipyretics, such as antipyrine, antifebrin, or phen- 
acetin. 

As soon as the acute symptoms have passed, and vaginal touch 
informs us that the effused material is becoming thoroughly organized, 
a further effort should be made to break up the morbid train before it 
passes on to suppuration or into chronic induration, by the application 
of a blister, six by eight inches, over the hypogastrium. This should 
not be applied before febrile action and the most acute symptoms have 
disappeared. Some excellent authorities object to blistering, for fear 
of strangury resulting. We have never had to do otherwise than con- 
gratulate ourselves on its employment. Should the case tend to an 
acute course and suppuration be impending, this should be encouraged 
by constant poulticing. 

As soon as the acuteness of the attack has passed, until which time 
attention should be turned to quieting the general symptoms of inflam- 



PELVIC PERITONITIS. 475 

mation, some of the best authorities have advised that the iodide or 
bromide of potassium should be administered, the former in five-grain 
doses repeated every third or fourth hour, or the latter in doses of ten, 
fifteen, or even twenty grains, at the same intervals. At the same time 
that we are not prepared to deny the utility of these drugs, we confess 
that we have never been able to persuade ourselves that they really 
accomplish any good result. We therefore never employ them, but 
when the temperature has become normal and pain has subsided Ave 
have found the administration of iron in some easily digestible form 
(Blaud's pills, or tincture of the chloride, or Pizzola's iron peptones), 
with the addition of a mild laxative if necessary, to greatly hasten the 
absorption of the exudation. The use of mercurials, either in the 
form of small doses of calomel or bichloride or of inunction, has been 
carefully tried by us, without, in our opinion, warranting the danger of 
the involuntary production of salivation. 

It may be necessary to repeat the application of the blister before 
the case ends in suppuration or passes into the chronic stage. 

While the patient remains in bed, warm poultices or towels wrung 
out of warm water and covered by oil silk should be worn over the 
hypogastrium. An additional emollient remedy of great value is the 
persevering use of the warm douche for fifteen or twenty minutes, night 
and morning, after Emmet's method, already described. The fluid used 
should be as warm as the patient can bear it, and may be slightly medi- 
cated in the later stages by the addition of chloride of sodium, tincture 
of iodine, or iodide of potassium. The injections stimulate the absorb- 
ents, and at the same time quiet inflammatory action, in the perform- 
ance of which functions they are invaluable in these cases. 

As the third stage of the disease, or the stage of suppuration, merges 
into pelvic abscess, it will be best to postpone the consideration of its 
management to the chapter in which that subject is treated. We will 
merely state here that after an abscess has formed and evacuated itself, 
great care should be taken not to allow the patient to exert herself for 
several weeks for fear of a relapse, and even after she has left the 
house and begun to exercise regularly, during two or three menstrual 
periods she should confine herself to bed. 



CHAPTER XXXIII. 

PELVIC PERITONITIS. 



Definition. — Inflammation involving the peritoneum covering the 
female pelvic viscera, and limited to it, receives the name of pelvic 
peritonitis. It must not be supposed that by this definition is meant 
simply that form of peritoneal inflammation arising in the pelvis and 
spreading into general peritonitis, which has long been described as 
metro-peritonitis. The disease that we are now considering is one 



476 PELVIC PERITONITIS. 

usually strictly limited to the pelvis, presenting symptoms peculiar to 
itself, and rarely passing into the general form of the same disorder. 

History. — Long before pelvic cellulitis was known, peritonitis, lim- 
ited to the serous covering of the pelvic organs, had attracted atten- 
tion, and its clinical resemblance to cellulitis, as subsequently described, 
fully noted. Thus Morgagni l relates a case in which, thirty days after 
delivery, the right ovary and tube were adherent to the colon and 
almost destroyed by an abscess. Nauche, in his work on Diseases of 
the Uterus, published at Paris in 1816, described inflammation of the 
uterus as affecting, first, the mucous membrane ; second, the paren- 
chyma; and, third, the serous covering. In 1828, Mad. Boivin -cred- 
ited the adhesions resulting from this affection and binding the uterus 
down with a large number of abortions attributed to other causes, and 
in 1833 she described immobility of the uterus, for which she gave as 
causes peritonitis, metro-peritonitis, and pelvic abscess. In 1839, 
Grisolle 2 distinctly stated that u there are cases of circumscribed peri- 
tonitis which, producing a tumor appreciable to sight and to touch, may 
lead to the belief in the existence of phlegmon " — i. e. a tumor the 
result of inflammation of areolar tissue. Lisfranc, 3 writing ten years 
after Boivin and Duges, copies their description very closely in his 
article on "Fixite de la Matrice " without referring to them, and like 
them attributes it to peritonitis or metro-peritonitis. 

Although these facts were known and universally admitted, they 
attracted little notice, and after the description of pelvic cellulitis by 
Doherty and Marchal de Calvi pelvic peritonitis was almost entirely 
lost sight of. This was due to the fact that the enthusiasm created by 
the description of a long-forgotten affection caused observers to look 
upon the results of peritonitis as those of cellulitis, and to describe 
them as such. Thus the matter rested until 1857, when Bernutz, in 
a treatise . written in concert with M. Goupil, not only drew especial 
notice to it, but took the position that inflammation of the cellular 
tissue immediately around "the uterus, described by JSonat as " phleg- 
mon periuterin," or what would strictly be termed, in our nomen- 
clature, "peri-uterine cellulitis," did not exist as a pathological reality, 
but that the lesions ascribed to it were absolutely due to pelvic peri- 
tonitis. 

These views, published at first in the Arcltiv. gen. de Med.* are 
fully elaborated in the admirable work 5 of these observers more recently 
brought forth. They do not touch the general subject of peri-uterine 
cellulitis as it exists in the broad ligaments, subperitoneal tissue, and 
around the rectum, but only that variety supposed to have its seat in 
the areolar tissue between the uterus and peritoneum. 

It has been already stated that Bernutz was incited to his inves- 
tigations by certain views advanced by Nonat as to the pathology 
of para-uterine induration, which sometimes goes on to suppuration. 
But his researches served not only to settle this comparatively unim- 
portant point ; they proved the fact, for which the investigator appears 

1 Artie. 22, epi*t. 46 ; Xonat, op. cit., p. 234. 

2 Bernutz and Goupil, op. cii., p. 398. 3 Clin. Med., vol. iii. p. 514. 

4 Archie, yen., 1857. 5 Clin. Med. des Femmes, 1862. 



HISTORY. All 

to have been himself entirely unprepared in the beginning, that many 
of those cases regarded as instances of non-puerperal cellulitis are in 
reality not phlegmonous but peritoneal inflammations. Since the pub- 
lication of these views we have directed our attention particularly to 
this point, and from careful observation, both clinical and post-mortem, 
feel warranted in recording the conclusions at which we have arrived in 
the following propositions : 

1st. Para-uterine cellulitis is rare in the non-parous woman, while 
pelvic peritonitis is exceedingly common. 

2d. A very large proportion of the cases now regarded as instances 
of cellulitis are really those of pelvic peritonitis. 

3d. The two affections are entirely distinct from each other, and 
should not be confounded simply because they often complicate each 
other. They may be compared to serous and parenchymatous inflam- 
mation of the lungs, — pleurisy and pneumonia. Like them, they are 
separate and distinct ; like them, affect different kinds of structure ; 
and like them, generally complicate each other. 

4th. They may usually be differentiated from each other, and a neg- 
lect of the effort at such thorough diagnosis is as reprehensible as a 
similar want of care in determining between pericarditis and endocarditis. 

Bernutz cites the results of five autopsies 1 by himself, and be- 
tween twenty and thirty by others, which presented all the signs of 
pelvic peritonitis and none of cellulitis, although during life the symp- 
toms and signs generally attributed to the latter disease were present. 
As an example conveying some idea of the close clinical resemblance 
between his cases found in autopsy to be peritonitis and those ordinarily 
regarded as cellulitis, we quote the salient points in his sixth observation : 

Patient 33, lymphatic temperament, entered hospital November 24th 
for feebleness, pain in the back, emaciation, and dysmenorrhea. After 
a while loss of appetite, increase of pain, and chills appeared. By 
touch the uterus w r as found completely fixed low down in the pelvis and 
inclined to the right side, and attached to it a very sensitive tumor the 
size of a hen's egg, extending behind the womb. On the 15th of 
December this tumor was as large as a turkey's egg. February 1st, 
tumor only the size of a pigeon's egg ; a circumscribed tumor on the 
left attached to uterus and to walls of the pelvis. March 23d, uterus 
movable and tumor reduced to the size of a little nut. April 4th, she 
died, and autopsy showed tubercular pelvic peritonitis, evidenced by 
tubercular deposit, lymph, pus, firm old adhesions, ovaries imbedded in 
false membrane and nearly destroyed. 

[I had often been struck by the great similarity between peritonitis and 
many of the cases of what, until enlightened by Bernutz, I had regarded 
as cellulitis, and by the fact that they occasionally ran into general peritonitis 
without any apparent emptying of purulent collections into the peritoneal 
sac, but 1 never had an opportunity of examining such a case post-mortem 
until the following presented itself: 

Mrs. M , aged thirty-five, married, but never pregnant, had been 

under my care during the winter at the Woman's Hospital for anteflexion 
of the uterus, the result, as I supposed, of peri-uterine cellulitis. August 

1 I have rejected a number of the eases reported, because not sufficiently conclusive. 



478 



PELVIC PERITONITIS. 



6th, I was called to see her in consultation with Dr. Roth, her family physi- 
cian, and found her suffering from severe pelvic pain, constant vomiting, and 
fever. Upon vaginal touch I found the uterus immovably fixed and the 
pelvic roof as hard as a board. The pelvic tissue was everywhere hard and 
resisting, and the physical signs of what I had habitually styled cellulitis 
were present. About a week afterward the patient died suddenly and unex- 
pectedly, and I made an autopsy in presence of Drs. Roth and J. C. Smith. 
No general peritonitis existed ; the left ovary presented a sac the size of a 
hen's egg, filled with pus ; the pelvic peritoneum was intensely inflamed, and 
the uterus bound down by old false membranes, bands of which matted all 
the parts together. The vermiform appendage was bound to the right ovary 
and the caput coli just below the uterus. No trace of inflammation could 
be discovered in the pelvic cellular tissue, except, of course, that in imme- 
diate contact with the ovary. 

The fixation of the uterus, observed during life, was due to lymph effused 
upon the pelvic peritoneum, and no trace of inflammatory action in the pelvic 
areolar tissue could be discovered as accounting for it. It is true that the 
left ovary, enveloped by the layers of the broad ligament, was inflamed, and 
that a certain amount of inflammation existed in the cellular tissue imme- 
diately surrounding it, but this did not extend. — T. G. T.] 

Frequency. — A reference to the autopsic notes of cases of cellulitis 
— for example, those recorded by West, Nonat, Aran, and McClintock 
— will give abundant evidence of the almost universal attendance of 
this complication upon it." But even without the existence of that dis- 
ease Aran found it in greater or less degree in 55 per cent, of cadavers 
of women examined in his service. This proves that peritonitis, limited 
to the pelvic viscera, is a common affection and one which is very gen- 
erally overlooked. It is probably to its occurrence that are due so 



Fig. 236. 




The straight line represents approximately the Roof of the Pelvis 

it more exactly. 



the dotted line represents 



many of those attacks of violent hypogastric pain occurring with men- 
struation or just after it, accompanied by vomiting and slight febrile 
action, and which are generally treated by domestic remedies and 
viewed as cramps or uterine colic. 



PATHOLOGY. 



479 



Pathology. — The disease runs its course here, as peritoneal inflam- 
mation does elsewhere, in three stages. In the first there are simple 
engorgement and turgescence of the vessels, producing redness, dry- 
ness, and pain. In the second stage an entirely different state of things 
will be found to exist, to comprehend which fully the reader must bear 
in mind what is meant by the "roof of the pelvis." If a plane be 
passed backward from a point just under the pubic arch, through the 

Fig. 237. 




The Reflections and Pouches of the Pelvic Peritoneum (Hodge). 

cervix uteri at the attachment of the vagina, to the sacrum at the 
attachment of the utero-sacral ligaments, it will correctly represent this 
roof, which is thus formed by the vesico-vaginal septum, the lower 
extremity of the uterus — which projects, as it were, through a hole in 
the roof — the upper part of the fornix vaginae, and the utero-sacral 
ligaments. Above the plane the organs of reproduction float, as Nonat 
expresses it, "in an atmosphere of cellular tissue." Let the reader 
suppose that, instead of this yielding, springy tissue, these organs were 
fixed in their places by having a fluid mixture of plaster of Paris 
poured around, among, and over them, which had afterward become 
solid, and he may form a correct idea of what vaginal exploration will 
yield to the sense of touch in the second stage. The roof of the pelvis 
is hard, ligneous, and as if composed of a "deal board," to which 



480 



PELVIC PERITONITIS. 



Professor Doherty likens it, The uterus, which is generally much dis- 
placed, is immovable, and all its appendages appear fixed by some solid 
surrounding element. 

This, the second stage, consists in a collection of plastic lymph oa 



Fig. 238. 




Perpendiciilar Section of Pelvic Cavity, showing Extent and Relations of Pelvic Peritoneum 

(Spiegelberg). 
P, P, peritoneum ; E, rectum ; U, uterus; B, bladder, distended ;. 8, symphysis pubis. 



the surface of the peritoneum, and of serous, purulent, or sero-purulent 
fluid in its most dependent parts. 

In the third stage the fluid, if serous, is absorbed ; if purulent, dis- 
charged, and the exuded lymph undergoes organization and subse- 
quently contraction. This binds the uterus, its appendages, and some 
of the intestines together in a mass which yields all the physical signs 
of a tumor. 

Causes. — Its causes are the following : 

Para-uterine cellulitis ; 

Parturition or abortion ; 

Gonorrhoea ; 

Endometritis, ovaritis, or salpingitis ; 

Escape of fluids into the peritoneum ; 

Traumatic influences ; 



CAUSES. 181 

Imprudence during menstruation ; 
Tuberculous or cancerous deposit. 
Its frequent dependence on the first needs no further mention. 

As a result of parturition or abortion it is so well known as to make 
the exhibition of proof here almost unnecessary. Reference may be 
made, however, to 53 autopsies by Aran, 1 in which, out of 38 women 
who had borne children, 24 presented evidences of its previous exist- 
ence, while out of 15 who were nulliparous only 5 did so. 

Gonorrhoea, by passing into the uterus and through the Fallopian 
tubes, is a fruitful source of the affection. According to Bernutz, 
28 out of 99 of his cases had this origin. We have seen a number of 
severe cases due to it, and the great importance attached to this cause 
by Noeggerath is elsewhere fully stated. 

It would be strange if endometritis and salpingitis did not, at times, 
cause oophoritis and pelvic peritonitis. That they frequently do so is 
abundantly demonstrated by autopsies made after their existence both 
in the puerperal and non-puerperal states. 

Salpingitis causes it, not only by the extension of inflammation along 
the mucous into the serous membrane, which is continuous with it, but 
by emptying its accumulated pus into the peritoneal cavity. 

Escape of fluid into the peritoneum is an undisputed cause of this, 
as of general peritonitis. [I myself produced a well-marked case, which 
almost terminated fatally, by injecting a solution of persulphate of iron 
into the uterine cavity. The passage of the fluid through the tubes 
could not be questioned, for agonizing pain came on in less than three 
minutes, and continued up to the development of inflammation. — 
T. G. T.] This danger has caused the almost entire abandonment of 
intra-uterine injections on the part of the majority of practitioners, 
unless the cervix be previously dilated by tents. But many other 
sources from which fluid may enter the peritoneum exist ; as, for exam- 
ple, rupture of an ovarian cyst, discharge of tubal dropsy or of a pelvic 
abscess, intra-peritoneal hemorrhage, regurgitation of obstructed men- 
strual blood, etc. 

Traumatic agencies, as blows, falls, injury during labor, punctures, 
etc., may result in partial, as they do in general, inflammation of the 
peritoneum. 

During the performance of menstruation, a physiological function 
which involves ovarian rupture and produces hemorrhage, which must 
pass to the uterus by a narrow tube not permanently in immediate con- 
tact with the ovary, any degree of exposure must evidently tend to 
inflammation in the investing peritoneum. Of Bernutz's 99 cases, 20 
were thus produced. 

Tubercles deposited in the part, either on the peritoneum or in the 
tissue of the tubes or uterus, may, as they do elsewhere, result in 
secondary inflammation ; and cancerous or cancroid degeneration would 
be still more likely to produce the same result. 

In certain peculiar states of the system this affection is excited by 
the most trivial circumstances, and very commonly the physician is 
held to a severe account for the fatal issue of an affection which he as 

1 Op. n't., 718. 



482 PELVIC PERITONITIS. 

little expected to arise from his interference as the friends of the patient 
did. We have seen it excited by the passage of the uterine sound, the 
use of a small sponge tent, and in one case from the passage of water, 
used by vaginal injection, into the uterus. Dr. Barnes, in his late 
excellent work on the Diseases of Women, says : "I have seen fatal 
peritonitis follow the simple application of nitrate of silver to the cervix 
uteri." It should be the duty of every physician to shield an unfor- 
tunate brother practitioner by the protection which these facts legiti- 
mately afford him ; but it should equally be the duty of each to remem- 
ber this paragraph, the whole of which is italicized in Dr. Savage's 
work upon the Female Sexual Organs : " No surgical proceeding what- 
ever touching any part of the uterine system should be unattended 
by the precautions observed in operations of a grave character there or 
elsewhere ; in certain states of the general system, unforeshadowed by 
any recognizable peculiarity, the most trivial operation has been speedily 
followed by fatal peritonitis." 

Varieties. — This affection may assume either an acute or chronic 
form, though when it constitutes the principal disease it generally, in 
the beginning, presents the features of the former. When it occurs as 
a complication of tuberculosis or uterine disease, it often assumes from 
the beginning the chronic type. Besides these varieties there are two 
others which cannot be passed without notice — menstrual pelvic peri- 
tonitis, which becomes aggravated at periods of ovulation, and recurrent 
peritonitis, which lasts for many years, giving, however, immunity for 
long periods, and then recurring with great violence from a trivial 
cause. We have had many such cases, one of which lasted ten and 
another eight years. For eight, ten, or twelve months these patients 
enjoy an almost absolute immunity from the disorder; then, excited 
by some apparently insignificant cause, a severe and excessively painful 
attack comes on. Sometimes these attacks are complicated by cellu- 
litis, and a purulent accumulation frequently discharges itself through 
the pelvis as a consequence of them. 

Symptoms. — The acute form shows itself by — 

Pelvic pain and tenderness ; 

Sometimes great vesical irritation ; 

Usually increased thermometric range ; 

Nausea and vomiting ; 

Anxious facies ; 

Mental disturbance ; 

Tympanites. 
When a severe acute attack sets in, it may cause either a chill or a 
sensation of coldness so slight that the patient will not recall its occur- 
rence unless her attention be specially directed to it, or pain and fever 
may show themselves without this symptom. 

Pain is at times only moderate, but at others most severe. It may 
occur in paroxysms, which create the greatest agony and prostrate the 
patient by their severity. We have seen it amount to agony equal to 
that arising from the passage of a biliary calculus, causing the patient 
to roll in bed, seize the bed-clothes in the teeth, and cry aloud most 
piteously. As a rule, it is not so violent as this. Pain may show itself 



SYMPTOMS. 483 

quite early in the disease, or it may be preceded for several days by 
pelvic uneasiness and weight. 

Tenderness over the whole hypogastrium accompanies it to such a 
degree that even the weight of the bed-clothes is intolerable, and the 
patient, to relieve it, lies upon the back with the legs flexed in order to 
relax the abdominal muscles. 

The pulse shows in slight cases very little, and in severe cases a 
considerable amount, of febrile action. It is small and wiry, and 
increases in rapidity to 110 or 120 to the minute. 

The thermometric range is likewise variable. In the beginning 
of an attack, which may become a severe one, the range may be nor- 
mal or even below the normal standard. " Subnormal temperatures 
are especially common in peritonitis," says Wunderlich, "and always 
suspicious : death may follow them closely. High and rising temper- 
atures do not add, per se, arguments for an unfavorable termination, 
although adding; another dangerous element to the case. It is not so 
much the actual height as its constancy which must be feared, as are, also, 
great and irregular fluctuations between very high and very low temper- 
atures." When, however, a case commences with a temperature of 106°, 
it is greatly to be feared that it will run a violent and dangerous course. 
On the other hand, even a normal temperature should not give complete 
security, although a decidedly favorable augury may usually be drawn 
from it. In general terms it may be said that for him who implicitly 
trusts to the revelations of the thermometer in this affection it will 
prove an unreliable guide ; but to him who looks upon them merely as 
aids to diagnosis and prognosis it will give decided assistance. 

Nausea and vomiting are common symptoms, though they do not 
generally exist to such a degree as to prove very annoying. 

The facies is peculiarly anxious, and is sometimes rendered very 
striking by the appearance of dark circles around the eyes. 

We have generally noticed in acute cases that the mind is markedly 
disturbed, as if the patient instinctively dreaded some serious disease, 
and even in chronic cases there is a decided tendency to slight mental 
alienation. In several cases we have seen this advance to absolute 
insanity. 

It may be justly observed that these are the symptoms which mark 
general peritonitis. This is true ; it is merely the slighter degree of 
severity and the localization of pain and tenderness which will point 
to the partial nature of the affection. 

.With reference to general peritonitis, it may be stated that, on the 
one hand, it, of all diseases, may declare itself by the most numerous 
and characteristic symptoms, or, on the other, run its fearful course 
with the greatest obscurity, so as to mislead the most careful diagnos- 
tician even up to its latest stages. If this be true as to the general 
disorder, how much more must it be so as to the local ! Thus it is that 
we find the subacute and chronic forms passing off without recognition. 
and the fact that they have existed is known only by the discovery oi' 
firm adhesions over the whole pelvic roof in post-mortem examinations. 
In these varieties there 1 are loss pain and tenderness ami less tendency to 
nausea- and febrile action than in the acute. Sometimes, indeed, there 



484 PELVIC PERITONITIS. 

is merely a sense of local discomfort, increasing to pain at menstrual 
periods, accompanied by fever toward evening, by difficulty in locomo- 
tion, and by a general sense of feebleness and malaise. This remark- 
able absence of symptoms in pelvic peritonitis was announced by Aran, 
and Dr. Dunean 1 expresses himself upon it in these words: "I might 
adduce cases of gonorrheal ovaritis commencing in healthy young girls, 
and ending in the fusion of all the parts in the pelvis into a solid, 
immovable mass, without the patient losing a cheerful and even gay 
visage, or making any great complaint of pain, unless interrogated 
closely, and then alleging the chief suffering to be from irritable 
bladder." 

We ourselves have examined many women, married and unmar- 
ried, parous and nulliparous, in whom a rigid vaginal vault, immovable 
uterus, and adherent ovaries and tubes unquestionably denoted the 
previous occurrence of pelvic peritonitis, but who absolutely denied 
any knowledge of such an illness or of ever having spent even a day 
in bed. The only thing they had to complain of was deep-seated pelvic 
pain of a more or less intermittent character existing for one or more 
years, or present at some previous time and followed by gradual relief. 

Physical Signs. — Should an examination be made during the first 
stage, nothing will be ascertained but the existence of sensitiveness 
upon pressure in the vaginal cul-de-sac and upon lifting the uterus. 
Tenderness will likewise be demonstrated by pressure on the hypogas- 
trium. None of that doughy, cedematous, puffy feel which accompanies 
cellulitis will be discovered by vaginal touch. Should the disease run 
its course as one of those very insignificant attacks which produce no 
grave symptoms and are scarcely recognizable, no other physical signs 
will present themselves at this or any other period. Should it be one 
of graver character, a sense of resistance merely, or a tumefaction like 
an ill-defined tumor, may be felt in the recto-vaginal space or at the 
side of the uterus. Or if very little lymph and much sero-pus have 
been the result of inflammatory action, a sense of fluctuation may be 
detected very early. The uterus is always more or less interfered with 
in its mobility, and in severe cases it is absolutely fixed. This explains 
how Lisfranc and Boivin applied to it the name of " fixity" or " immo- 
bility" of the uterus. 

We have stated that a tumor is commonly felt posterior to, or at one 
side of, the uterus. This tumor, which is formed by agglutination of 
the pelvic and abdominal viscera, is extremely sensitive to touch. 

If the disease go on to 'formation of pus, the sense of tumefaction 
may disappear as this discharges itself; but if the effused lymph become 
thoroughly organized, it remains hard and resisting for a length of time. 
This accumulation almost invariably displaces the uterus, sometimes by 
pressing it in an opposite direction, sometimes by drawing it toward 
itself as the lymph contracts. 

[In a case which I saw some years ago with the late Prof. G. T. Elliot we 
were much puzzled for a short time before its fatal issue by the existence in 
the fornix vaginae of a pouch apparently filled with fluid, all the surround- 

1 Perimetritis and Parametritis, p. 78. 



COURSE-PARA-UTERINE CELLULITIS. 485 

iiig parts being unattached and no sense of tumefaction or resistance being 
discoverable. The patient died suddenly from general peritonitis, and upon 
post-mortem examination, conducted by Prof. J. W. S. Gouley, we found, 
first, a small piece of fetid placenta in utero, the result of a recent abortion ; 
second, an abscess of the right ovary, which had created general peritonitis 
by emptying itself into the peritoneum ; and, third, pelvic peritonitis, which 
had evidently existed for more than a week. It had created a purulent col- 
lection in Douglas's cul-de-sac, which was limited to this space by false mem- 
branes that formed for it a complete roof. This accumulation it was which 
gave the sensation above described. 

In another case, sent to me by Prof. J. C. Hutchinson of Brooklyn, the 
uterus was found firmly bound to the sacrum by a hard, resisting mass which 
was very sensitive. There was considerable corporeal endometritis, and I 
incautiously applied to the uterine cavity tincture of iodine, and as a result 
the most violent pelvic peritonitis developed itself, which almost became 
general. In ten days after its inception a soft, fluctuating pouch formed 
in the fornix vaginae, which became so painful that I tapped it with an 
exploring needle and drew off about an ounce of clear serum, much to the 
patient's relief.— T. G. T.] 

Course, Duration, and Termination. — In no disease can these be 
more variable and uncertain than in that under consideration. A great 
similarity exists between its phases and those of pleuritis. As in that 
affection we have shades of difference varying from the ordinary " stitch 
in the side," which results from inflammation of a portion of the pleura 
not larger perhaps than a silver half dollar, to empyema and tubercular 
pleuritis, which may continue till death by pulmonary consumption or 
pneumothorax closes the scene, so may we have in pelvic peritonitis like 
variations. It may run its course unobserved, leaving evidence of its 
existence only in adhesions found post-mortem. It may pass through 
its first two stages in three or four weeks, leaving the uterus per- 
manently displaced by the continuance of the third. It may reappear 
with a certain amount of acuteness at menstrual periods, causing them 
to be very painful. It may, if due to tubercular deposit, continue so 
as to exhaust the patient slowly. It may produce a purulent collec- 
tion, which, by emptying itself into the peritoneum through the adhe- 
sions thrown around it, may create general peritonitis, or this last may 
result from the spread of morbid action from the pelvic to the general 
serous membrane. 

Differentiation. — The diseases with which this is most likely to be 
confounded are — 

Para-uterine cellulitis ; 

Pelvic hematocele ; 

Fibrous tumors ; 

Fecal impaction. 
Para-uterine Cellulitis. — Differentiation between these two affec- 
tions is in some cases simple enough, but in others it is impossible. 
Difficulty will occur when cellulitis affects, and is confined to, the tissue 
most immediate to the uterus, but this we know to be very rare. Our 
suspicions will often be turned into the proper channel by the cause of 
the attack. Cellulitis will very rarely occur except after parturition. 
abortion, or an operation on the pelvic viscera. Peritonitis will usually 



486 PELVIC PERITONITIS. 

result from exposure during menstruation, disease of the ovaries, or 
escape of fluid into the peritoneum. Should the attack occur as a 
result of gonorrhoea, it is probably due to serous and not cellular 
inflammation — a fact which the anatomical relations would lead us a 
priori to anticipate, and which is fully substantiated by statistics. West 
and Aran credit gonorrhoea with the causation of cellulitis in from 1 to 
2 cases in 100, and Bernutz declares it active in 28 Out of 100 of 
peritonitis. 

Pelvic Hematocele. — From this it may be distinguished by the 
great suddenness of appearance of hematocele, absence of signs of 
inflammation in the beginning, presence of those of hemorrhage, and by 
the much greater dimensions of the tumor, which, unlike that of peri- 
tonitis, is at first rather soft and gradually becomes hard. The occur- 
rence of free bloody flow will likewise point to hematocele, though such 
an occurrence, to a limited extent, often takes place in peritonitis. 
Hematocele often excites peritonitis, and thus both frequently exist 
together. 

Fibrous Tumors. — These will generally be known by their pro- 
ducing no pain, presenting no sensitiveness on pressure, no sense of 
oedema, no signs of inflammation nor rapidity of development. They 
are likewise usually movable, and cause no fixation of the uterus. 

Fecal Impaction. — After pelvic peritonitis and cellulitis have existed 
for some time, and have lost their features of acuteness, and more espe- 
cially after opium has been long used to allay the pain which attends 
them, they are very apt to be complicated by fecal impaction. Not 
only is this a complication ; we have known it exist long after the 
inflammatory affection which preceded it has passed away, and give 
rise to the belief that this still continues, the pain which it creates 
being attributed to the primary condition. We have met with several 
very striking cases in which, after four or five months of intense suffer- 
ing from supposed peri-uterine inflammation, which was treated by free 
use of opium, we discovered great fecal impaction, the removal of 
which afforded complete and permanent relief. So frequent do we con- 
sider the development of this condition as a result and complication of 
peri-uterine inflammation, or as an independent state which is mistaken 
for it, that we never take charge of a case which has been under the 
previous treatment of others without examining for its existence, and 
in the management of cases from the commencement under our charge 
always carefully guard against its occurrence. 

Importance of Differentiating Peritonitis from Cellulitis. — The 
importance of differentiating this disease from cellulitis rests in part 
upon the fact that it admits of less local interference. Sometimes the 
passage of a uterine sound, an application to the cavity, or even the 
use of a vaginal injection which by accident has entered the uterus, has 
been known to destroy life by causing peritonitis which has extended 
to the whole peritoneum. It is likewise important in reference to prog- 
nosis as to the course of the affection and its remote results. Lastly, it 
should not be forgotten that progress in the comprehension of the dis- 
eases of all organs must be preceded by a careful and systematic sepa- 
ration of them, one from the other. As the study of acute cardiac 



PROGNOSIS— TREA TMENT. 487 

affections under the common name of carditis could never have accom- 
plished what that of each of its varieties has done, so could not inves- 
tigation of these affections undivided into their proper classes. 

Prognosis. — If the case follows parturition or abortion, the progno- 
sis will be rendered graver by that fact. Otherwise it will be governed 
in great degree by the general symptoms. Should these show great 
intensity of inflammation, and constitutional disturbance be evidenced 
by excessive nausea and vomiting, quick pulse, anxious facies, etc. — 
in other words, should the symptoms point to the probable spread of the 
disease over the whole serous sac — the ordinary prognosis of peritonitis 
may be made. In cases of chronic type occurring in the non-puerperal 
state it is decidedly favorable, unless the disease exist in a scrofulous 
or tuberculous patient or show" a tendency to severe periodical relapses. 
Another fact which will increase the gravity of prognosis is the exist- 
ence of purulent effusion in place of lymph and serum as the result of 
the inflammatory action. Seeing, as we do, between 500 and 1000 
cases of pelvic peritonitis every year, our experience is that so small a 
proportion terminate fatally, at least in consequence of the results of the 
acute attack, that we are inclined to place the mortality at a very low 
figure, and therefore usually give a favorable prognosis. It is, how- 
ever, always prudent to guard ourselves by warning the friends that 
the occurrence of suppuration or of a repetition of the acute symptoms 
may require operative interference, and may possibly terminate dis- 
astrously. 

Results. — The common results of the disease, which remain long- 
after it has passed away or perhaps permanently, are — injury of the 
ovaries by abscess or atrophy ; obliteration or dropsy of the Fallopian 
tubes; and fixation of the womb in malposition by organization of 
false membranes. As consequences of these lesions follow, very natu- 
rally, amenorrhoea, dysmenorrhoea, and sterility. 

Treatment. — Pelvic peritonitis usually announces its advent by 
severe pain, elevation of temperature, rapidly of pulse, and other 
symptoms which leave the practitioner in no doubt as to its develop- 
ment. The rule of treatment should be based upon the following indi- 
cations : first, entire prevention of pain during its course ; second, 
complete control of the temperature ; third, the strict observance of 
absolute quietude. The patient's prospect for life and for escape from 
the chronic results of the disease if recovery occurs will greatly depend 
upon the thoroughness with which these indications are fulfilled. 

In the very commencement of the attack pain should be relieved by 
opium administered by the hypodermic syringe, the mouth, or the rec- 
tum. The first method is an excellent one to begin with, but its fre- 
quent use is so apt to engender a morbid taste that it is better after 
pain has once been completely subdued to continue the narcotic influ- 
ence by opium or morphia by mouth or rectum. 

Formerly, following the precepts of the late Dr. Alonzo Clark of 
this city, opium was considered the sheet-anchor in all eases of perito- 
nitis, general or local, and was administered not only for the purpose 
of relieving pain, but also in order to quiet the movements of the 
intestines, and thereby, as it was supposed, check the progress of the 



488 PELVIC PERITOXITIS. 

inflammation. Undoubtedly, this practice was excellent for a time, 
but it had its objections in that the constipation induced by the stead y 
administration of opium required the use of strong cathartics later on. 
by which a fresh inflammation was very liable to be lighted up, not to 
mention the accumulation of gas and the reflex gastric disturbance 
which the arrest of intestinal action produced. Of late years our prac- 
tice in this respect has diametrically changed, since we now have sub- 
stituted the administration of mild laxatives, such as small doses of 
calomel frequently repeated, followed by saline laxatives as soon as 
tympanites or the first symptoms of peritoneal inflammation manifest 
themselves. It is a fact now beyond dispute that the relief of tym- 
panites produced by a free evacuation of the bowels will almost invari- 
ably cut short an incipient attack of peritonitis, as evidenced by the 
falling of temperature, the cessation of vomiting, and the general 
improvement of the patient. We therefore nowadays find that out- 
patients do best by keeping the bowels moderately loose through the 
administration of gentle laxatives or daily warm water and glycerin or 
sweet oil, or if necessary oxgall, enemas ; pain, of course, following 
such evacuations being relieved by the moderate use of opium. 

In a certain number of diseases death is in great degree due to the 
very high temperature which attends them. Examples of such are 
sunstroke, typhoid fever, septicaemia, and peritonitis. In all these the 
greatest advantage results from keeping the temperature at or near the 
normal standard. This being done, the altered blood-state and its 
remote influences upon the tissues composing the nervous system and 
important viscera, which result from an exaltation of the animal heat, 
are avoided, and thus, although death may come through some other 
avenue of approach, this one is obstructed. 

It is seldom in local peritonitis to find the temperature so persist- 
ently high as to be a serious cause for alarm. As a rule, it varies 
between normal and 103°-104° F.. changing several times during the 
twenty-four hours, usually reaching the higher figure toward evening ; 
but no certain estimate of temperature can be given for a case of pelvic 
peritonitis, since it may be normal for several days ; then, with or with- 
out fresh accession of pain, rise to 103° or more, remaining near this 
point for several days, and then again, under appropriate treatment, 
dropping to near the normal figure. Such rapid rises of temperature 
usually indicate, in the early stages of the disease, a fresh exudation ; 
that is to say, a more or less marked increase of the inflammation. 
This may not always be susceptible of recognition by the examining 
finger. In the later stages such fluctuations of temperature, especially 
if accompanied by more or less pronounced rigors and perspiration, 
may indicate the development of suppuration in the exudation. 

This condition of things may continue for weeks, and even months, 
and completely exhaust not only the patience and endurance of the 
patient, but also the resources of the physician. 

According to the degree of temperature — that is to say, if it exceeds 
102° F. — the necessity for controlling and subduing it arises. This 
might be done by lowering the temperature of the whole body through 
cold affusion, cool baths, or the cold pack : but in cases of protracted 



TREATMENT. 489 

illness we must avoid the risks of sudden and excessive reduction of 
temperature ; hence we have abandoned at present all violent methods 
of lowering body-heat, and have limited ourselves to the measures 
which control the local inflammation and thereby indirectly the general 
rise of temperature. The application of the rubber ice-bag (preferably 
that known as the German ice-bag covered with mackintosh) or of the 
ice-water coil, or in milder cases of cold compresses frequently repeated, 
constitutes the limit of the local antiphlogistic measures. We have 
already stated, in the chapter on General Therapeutics, our views on 
the reduction of temperature by means of medicinal agents ; suffice it 
to say here that the careful administration of antipyrine, antifebrin, 
or phenacetin whenever the temperature seems to demand their use is 
the rule with us, and forms in our opinion an invaluable method of 
reducing temperature and giving the patient time to recover from the 
disease. 

The application of leeches to the abdominal skin over the seat of 
the exudation is a favorite means in the hands of many prominent 
practitioners for checking the spread of the exudation and relieving 
the high temperature. We can sanction their employment only at the 
very outset of the disease, when possibly they may entirely abort it ; 
but, unfortunately, we seldom have the opportunity to see the cases 
early enough to warrant the remedy ; besides, unless carefully watched, 
more blood may be lost after the leeches have been removed than is 
desirable. 

Perfect quietude should be observed. Not an approximation to it, 
but a stillness which should interdict the action of every voluntary 
muscle. A nurse should watch the patient night and day, anticipate 
every want, and supervise every function. The patient should not con- 
verse with her, and no one else should be habitually in the chamber. 
It is well to keep the bladder empty by the catheter if urination is not 
easy. Milk, beef-tea, and other plain, nutritious, and unstimulating 
food should be prescribed, but no solid food should be allowed. 

In the second and third stages, where lymph has been the chief and 
perhaps the only product of inflammation, we must rely upon counter- 
irritants, and we know of none to be compared with the blister. One 
made of Spanish flies, four by six inches in dimensions, should be 
applied over the hypogastrium, and the abrasion which it produces 
dressed with savine ointment. As soon as it heals entirely another 
should be applied directly over the newly-formed skin, and this may be 
repeated every ten or fourteen days with great advantage. We have 
known patients who dreaded them in the beginning beg for them after 
experiencing the relief which they gave. The blister is to pelvic peri- 
tonitis in its later stages what it is to pleuritis, the most rapid and 
efficient of remedial agencies. In place of the blistering plaster, which 
often causes very severe pain, the cantharidal collodion may be painted 
on the abdomen over the exudation twice a day, until the desired vesi- 
cation is produced. 

Another very excellent method for producing counter-irritation is 
by tincture of iodine painted over the hypogastrium once in twenty- 
four hours for weeks. 



490 PELVIC PERITONITIS. 

As soon as a thorough blister has been raised, flaxseed poultices, 
prepared as hot as the patient can bear them, should be applied and 
continued as long as the persistence of the exudation requires. It is 
our rule to have them applied so hot as to produce ecchymoses of the 
skin, covering them with oil-silk and flannel in order to prevent too 
speedy evaporation. The more thorough the blistering and the hotter 
and more persistent the use of the poultices, the sooner will the absorp- 
tion of the exudation take place. This treatment is applicable, of 
course, only to those cases where the exudation can be felt through the 
abdominal Avails, and not to those where it is situated deep in the pel- 
vic cavity and accessible only through the vagina. 

Treatment of Clironie Cases. — The affection having passed into the 
chronic stage or originated with all the appearances of chronic disease, 
a different course of management becomes advisable. The patient 
should not be so strictly confined to bed nor dieted. She has entered 
upon an invalid course which may last for months or for years, and in 
making a strenuous effort to cure her local disorder we may sap her 
general health and do her irretrievable injury. On the other hand, 
she should not attend to her household cares nor take exercise to any 
great degree, but, remaining in bed or on a lounge most of the time, 
go out in the fresh air for an hour or two daily. Her diet should be 
of the most nutritious character, stimulants should be allowed in mode- 
ration, and the impoverished blood resulting from a combination of cir- 
cumstances prejudicial to hematosis combated by change of air and the 
use of vegetable and mineral tonics, especially iron. 

One of the most important questions in the management of chronic 
cases is that of the amount of exercise to be allowed and the strictness 
of confinement to be practised. No absolute rule can be laid down in 
reference to these points, for each case will call for special guidance 
based upon careful experiment. In general terms it may be stated 
that when motion does not produce pain or discomfort, the patient 
should ride in an easy carriage for two or three hours daily ; in those 
cases which are still more free from local trouble she may walk with 
moderation ; while in others which present elements of acuteness no 
motion whatever should be allowed. Sometimes the patient will even 
bear removal from home to the seaside or some watering-place during 
the summer. If this be so, a locality should be chosen that is access- 
ible by easy travel. One great and ever-recurring difficulty in this 
connection arises from the great tendency of patients, allowed to take 
exercise, to commit indiscretions by overtaxing themselves. This 
becomes so great at times as to make it advisable to confine to bed one 
who would be benefited by moderate exercise, in order to avoid danger 
from her imprudence. The fact should never be lost sight of that the 
pelvic peritoneum forms a part, a sheath, as it were, of the suspensory 
ligaments of the uterus. The fibrous structure of the round, broad, 
sacral, and vesical ligaments is covered by it, so that dragging of the 
uterus upon them puts the peritoneum upon the stretch and strongly 
tends to excite renewed action there. 

Of all influences which act in a directly prejudicial manner upon 
these cases, sexual intercourse is the most decided, and its strict limi- 



TREATMENT. 491 

tation should be made one of the first rules laid down for their man- 
agement. 

Should acute exacerbations occur in chronic cases, the use of local 
depletion is advised by high authority ; but as a plan to be strictly 
pursued with reference to cure it is highly objectionable on account of 
the spanaemia which it induces. 

If it be deemed advisable to keep up the use of the iodide or 
bromide of potassium — the results of which are, however, doubtful — 
they may with advantage be combined with iron and vegetable tonics, 
as in the following prescriptions : 

Up. Potassii iodidi, 3iij ; 

Ferri iodidi syr., |ij ; 

Tr. calombse, §vj. — M. 

A dessertspoonful (gij) in water three times a day. 

1^. Potassii bromidi, 3v ; 

Vini ferri dulcis, §iv ; 

Tr. calombse, 3iv. — M. 

A dessertspoonful in water three times a day. 

Should Collections of Pus or Serum be Evacuated ? — The important 
bearings of this question are manifest, but unfortunately no definite 
answer can be given to it. In evacuating these collections the peri- 
toneal cavity is not exposed to entrance of air, for a false membranous 
roof covers the collection, but there is always danger in perforating the 
delicate and easily inflamed serous sac. [I have elsewhere reported a 
case in which I drew oif one or two ounces of serum under these cir- 
cumstances, to the great relief of the patient, who rapidly improved and 
did well. It is not the only case in which I have ventured to invade 
the peritoneum under these circumstances. — T. G. T.] The safest rule 
for practice will be this : If in spite of the sero-purulent collection the 
patient be doing well and do not suffer from the local trouble, it should 
be left to empty itself spontaneously. [I do not agree with this advice 
on general principles, so far as it applies to the presence of pus. My 
opinion is that, pus being present and capable of evacuation without 
special trouble or danger, it should always be evacuated as soon as 
detected ; and I have no doubt that this is really Dr. Thomas's opinion 
also. — P. F. M.] If, on the other hand, the patient suffer from 
the collection, be not progressing favorably, and the evacuation be 
perfectly practicable, it should be accomplished. 

Methods of Evacuation. — Evacuation may be accomplished by the 
aspirator, a small trocar and canula, or by a guarded bistoury or tenot- 
omy-knife. After evacuation the sac may be carefully washed out with 
a weak solution of carbolic acid in warm water or of tr. of iodine in the 
same menstruum. 

[Pelvic Lymphangitis and Lymphadenitis. — That the lymphatic vessels 
and glands of the pelvic cellular tissue may become inflamed, and then give 
rise to symptoms similar to those of pelvic peritonitis and cellulitis, is to us 



492 PELVIC LYMPHANGITIS. 

unquestionable, and we confess our surprise that so little mention of this 
disease is made by modern authors. Lucas Championniere 1 of Paris in 1870 
called attention to the close connection between pelvic lymphangitis and 
puerperal inflammations, and both he and Leopold, 2 then of Leipzie. 
described the complicated network of lymphatic vessels enveloping and 
penetrating the uterus, tubes, ovaries, pelvic peritoneum, and cellular tis- 
sue. But Courty of Montpellier was the first 3 to recognize the existence 
of a non-puerperal inflammation of these vessels and glands, and to elevate 
that condition to the dignity of a separate disease. 

My attention was called to this subject by an article by Dr. J. S. Carreau 4 
of New York, and I then recalled having met similar cases. A full descrip- 
tion of this condition will be found in an article by me published in 1883. 5 

Causes. — These are the same as would produce an inflammation of the 
lymphatics in any other part of the body — viz. a traumatic irritation or a 
septic infection of an organ plentifully supplied with lymphatic vessels. 
Thus, injuries to the cervix and its cavity (laceration, curetting, caustics, or 
chronic catarrh of the cavity of the cervix, chancroid or septic infection) 
might produce a direct inflammation of the adjacent lymphatic vessels and 
glands. 

Diagnosis. — In place of the large exudate and the immovable uterus 
found in pelvic cellulitis, the vaginal vault in pelvic lymphangitis will be 
felt to be puffy, doughy, and above it the finger will detect bunches of 
exquisitely tender, slightly movable cords, similar to varicose veins, with 
irregular, smooth nodules here and there, which are immovable and also 
exceedingly sensitive. These cords and nodules are felt either directly 
behind the cervix or on both sides, and are evidently situated in the cel- 
lular tissue. Several times I have found them quite high up on the poste- 
rior surface of the uterus, the mobility of which organ is but little affected 
in this disease. 

Symptoms. — Deep-seated pain and throbbing in the pelvis, some rise 
of temperature in the early and acute stage, dyspareunia, are the chief 
symptoms. 

The treatment consists in hot douches, tr. iodine, and glycerin to the 
vaginal vault, and glycerin tampons. 

The course and termination of the disease, if it is properly treated in the 
early stage, are rapid recovery. When the inflamed glands have become 
indurated little can be expected from local remedies. A course of treat- 
ment by brine sitz-baths and douches would then probably offer the best 
chance for cure. — P. F. M.] 

1 Ut. Lymphatics and Ut. Lymphangitis, and the Part played by Lymphangitis in Puer- 
peral Complications and Ut. Diseases, Paris, 1870; and Arch, de Tocologie, 1875. 

2 Arch, fur Gyndk., 1873. 

3 Annal. de Gynecol., April, 1881 ; Maladies des femmes, 1883. 

4 N. Y. Med. Bee, July 2, 1881. 

5 " Non-puerperal Pelvic Lymphadenitis and Lymphangitis," Am. Journ. Obst., 
Oct., 1883, pp. 24. 



PELVIC ABSCESS. 493 



CHAPTER XXXIV. 

PELVIC ABSCESS. 

It would seem unnecessary to devote a special chapter to the con- 
sideration of pelvic abscess, which in the large majority of cases is a 
direct result of the inflammatory exudations described in the last two 
chapters, and which should therefore have been discussed under those 
headings. But suppuration often occurs in the Fallopian tubes and 
ovaries, and occasionally as the result of disease entirely unconnected 
with the pelvic organs, such as caries of the vertebrse, pelvic bones, 
inflammation of the psoas muscle, and all such accumulations of pus 
may be grouped under the one head of pelvic abscess. In order to 
avoid confusion we will say that we here consider only the abscesses 
ca.used by the suppuration of exudations in the pelvic cellular tissue, 
relegating the others to the chapters which treat of the diseases of the 
respective organs. 

Definition. — A pelvic abscess in the ordinary sense of the word 
would mean an accumulation of pus in any portion of, or within any 
organ situated in, the pelvic cavity. This is the usual acceptation of 
the term, from which, however, as above stated, we have decided to 
depart. 

Pathology. — There are four sources of pelvic abscess as ordinarily 
described : 1st, breaking down of tuberculous material deposited in any 
of the tissues of the pelvis ; 2d, suppurative action taking place in the 
walls of a cavity formed by an hematocele or ovarian cyst ; 3d, inflam- 
matory suppuration in the ovaries, the tubes, the pelvic peritoneum, or 
the parenchyma of the uterus itself; 4th, inflammatory suppuration in 
the para-uterine cellular tissue. 

The first source is very rare, and distinguishable only by the history. 
The second and third sources are considered under their respective head- 
ings. Abscess of the uterine tissue is rare and usually puerperal. We 
shall here discuss only the fourth variety, which is not uncommonly met 
with, and is most generally the result of cellulitis occurring after par- 
turition or in the non-puerperal state. Under the latter circumstances 
cellular inflammation may be primary, or secondary to irritation from 
some foreign body, as the debris of an extra-uterine foetus, a hard sub- 
stance in the vermiform appendix, a fibrous tumor of the uterus, or caries 
of the pelvic bones. 

Causes. — Any influence which induces cellulitis or either of the 
other two pathological conditions mentioned may prove immediately 
causative of abscess. As remote causes may be mentioned the tuber- 
culous and scrofulous diathesis ; great depression of the vital energies 
from any cause, as impure air, like that of a hospital ; the puerperal 
state ; and pyaemia. 

Symptoms. — These will not (lifter essentially from those oi' abscess 



494 PELVIC ABSCESS. 

elsewhere. When pus is forming, violent chills, followed by fever, with 
profuse sweating, are likely to occur. Then a feeling of prostration 
with throbbing pain in the pelvis, pressure upon the rectum and blad- 
der, and sometimes interference with urination, presents itself. Pain 
down the thigh, which may be mistaken for sciatica, will also at times 
be noticed. 

Physical Signs. — By abdominal palpation, combined with rectal or 
vaginal touch, a fluctuating tumor will be felt, presenting the ordinary 
physical signs of purulent collections elsewhere. 

Course, Duration, and Termination. — Pelvic abscesses may evacuate 
themselves through any part of the floor of the pelvis, through its roof 
into the peritoneum, through any one of its walls by means of foramina, 
through any of the pelvic viscera, or by several of these channels at 
the same time. They may open by free outlet or by a long, sinuous 
tract, which renders prognosis as to cure extremely grave. The most 
favorable points for evacuation are through the vagina and rectum. 
Next to these comes, in point of favorable prognosis, evacuation through 
the abdominal walls. [In the Charleston Medical Journal for 1853 I 
published a fatal case of rupture into the intestine and bladder, with 
autopsy. — T. G. T.] Sometimes, when left to themselves, these abscesses 
will go on to recovery without delay, opening into and discharging them- 
selves through some of the parts mentioned, and gradually contracting 
and disappearing. Sometimes, if deprived of the assistance of art, 
they may burrow deeply into the tissues, open by long, fistulous tracts 
into some organ, as the large intestine or sigmoid flexure, or discharge 
into the peritoneum, or honeycomb the pelvic cavity. 

Konig has instituted some very interesting experiments on the 
cadaver to show the most probable routes which these accumulations 
may take : 

1st. Injecting air or water beneath the peritoneum near the ovary 
or tubes, the injection ran along psoas and iliac muscles into pelvis. 

2d. Beneath lateral ligament near cervix, it filled the same side of 
pelvis, ran along round ligament toward Poupart's ligament and to the 
iliac fossa. 

3d. Beneath broad ligament behind cervix it filled posterior and lat- 
eral part of pelvis, and passed along psoas and iliac muscles into pelvis. 

Sometimes, even when the opening at first is large, it contracts so as 
to allow only an imperfect discharge of the contents of the sac. Then 
hectic fever arises, and the patient either leads a miserable existence for 
years from the constant fetid flow or is worn out by exhaustion or septi- 
caemia. At other times these collections of pus will remain imprisoned 
for a long period without any attempt at escape. 

Differentiation. — The morbid states with which this condition may 
be confounded are these : 
Pelvic hematocele; 
Extra-uterine pregnancy ; 
Displaced ovarian cyst ; 
Pyo-salpinx. 

The first of these, being a hemorrhage, gives certain symptoms 
characteristic of that accident, as prostration, coldness of the surface, 



PROGNOSIS— TREATMENT. 495 

suddenness of appearance, etc., and absence of chill, heat, fever, and 
other signs which are likely to accompany abscess. 

With the second the signs of pregnancy exist, and as early as the 
fourth month foetal movements may be detected, while the perfect health 
of the patient, with absence of menstruation, will excite suspicion as 
to the character of the affection. 

Around abscesses, even of tubercular character, there is always a 
wall of lymph thrown up which would not be present in a displaced 
ovarian cyst. All the rational signs of suppuration would likewise be 
absent in the latter. 

Accumulation of pus in the Fallopian tube is always the result of 
inflammatory action affecting the lining membrane of the organ and clos- 
ing both the uterine and ovarian extremities. The fluctuating tumor 
thus produced may be slender and small, or it may acquire the size 
of an ordinary breakfast sausage or become a globular, more or less 
distended, mass. It may be loose or it may be adherent to the bottom 
of Douglas's pouch. Errors of diagnosis are not infrequent, and often 
only the most experienced touch is able to differentiate between an intra- 
peritoneal abscess — that is, one situated in the ovary or Fallopian tube — 
and one located in the pelvic cellular tissue. The aspirator will enable 
the operator to ascertain whether the mass contains pus or some other 
fluid. As regards the prognosis and treatment, it is of the greatest 
importance that the intra- or extra-peritoneal location of the abscess 
should be determined. A serous accumulation in the Fallopian tube 
may simulate a pyo-salpinx, but does not present the history of inflam- 
mation and suppuration characteristic of the latter. 

Prognosis. — The prognosis will depend upon the following circum- 
stances : It will be favorable if the abscess be superficial, point upon a 
mucous tract, open low down in the pelvis by free exit, and give forth 
pus which has no offensive odor. Should it be deep-seated, open by a 
long tract, give forth fetid pus, open high up and by two points of exit 
— as, for example, the bladder and bowel — the prognosis is decidedly 
unfavorable, unless the case can be so affected by surgical interference 
as to change its character. 

Treatment. — Nothing can be done in these cases by specific medica- 
tion, by which we mean that directed especially to relief of the existing 
morbid condition. All of our efforts should be directed to supporting 
the vital forces, which are always much prostrated by the process of 
suppuration. The patient should take the most nutritious diet, as much 
animal food as she can digest, eggs, milk, fresh vegetables, and malt 
liquors. Whiskey or brandy should be allowed her, and the blood-state 
should be improved as much as possible by vegetable and mineral tonics. 
Those most especially suited to the condition are preparations of cin- 
chona and of iron, as, for instance, the following pill: 

1^. Quiniae sulphat., J}ij ; 

Ferri sulphat., Bj ; 

Acid, sulph. arom., gtt. x : 

Mucilag. acacise, q. s. — M. or ft. pil. No. xx. 

S. — One to be taken three times a day before meals. 

32 



496 PELVIC ABSCESS. 

But it is to surgery that Ave must look most confidently for aid, and 
in this connection arises the important question as to the propriety of 
opening such abscesses, the best point for evacuation, and the time for 
interference. 

Should an abscess in the pelvis show a rapid tendency to point and 
discharge through a favorable channel, at the same time that no dis- 
tressing or dangerous symptoms show themselves, it would be the part 
of wisdom to await the action of nature, for all must admit that there 
are feAV localities in the body into which it is more hazardous to cut 
than this. Even under these circumstances, however, there is danger 
in delay. Sir James Simpson relates a case which he saw with Dr. 
Ziegler one day when the abscess pointed decidedly toward the vagina 
and rectum very low down. Feeling sure that it must soon discharge, 
they left it till the next day, but before that time, to their surprise, it 
had burst into the peritoneum. This danger, as evidenced by statistics, 
is not great, and, as experience goes to prove that the knife is often 
employed too early rather than too late, I should strongly recommend 
the delay of surgical interference until the presence of pus is an abso- 
lute certainty. If it be thus delayed, the tissues intervening between 
the pus and point of introduction of the instrument become broken 
down, and a tract of sinus is avoided ; if two or three abscesses exist 
near each other, we give time for them to coalesce ; and the mass of 
lymph poured out is liquefied by the suppurative process. Should 
evacuation be resorted to too soon, all these advantages will be lost. 

Let us suppose a different case, that the patient is suffering grave 
constitutional signs from the abscess. The answer to the question of 
the propriety of interference resolves itself into this : if the pus can 
be certainly reached, it should be evacuated. Should the abscess be 
deeply seated, on the other hand, so as to make the operation difficult 
and uncertain, it would expose the patient to hazards greater than those 
attendant upon delay. 

Dr. Savage believes that "puncture should be practised early and 
per vaginam." Spencer Wells declares, from an experience in opening 
as many as from twenty to thirty pelvic abscesses, that he has known 
of no fatal result. " I have known," says he, "several cases of death 
where no puncture has been made — some of them very painful cases — 
when I had urged puncture and was overruled." As a rule he punc- 
tures per vaginam. 

Prof. Brick ell of New Orleans has recently taken strong ground in 
favor of the early evacuation of pelvic accumulations, and, as we espe- 
cially desire to lay before the reader an unbiassed view of the present 
state of professional opinion upon this important subject, Ave give his 
conclusions in full : 

"1. I have no doubt at all that there are two distinct forms of pel- 
vic inflammation — serous and phlegmonous or suppurative. An attack 
of either may be abortive — that is, may fail to result in formation of 
pus or effusion of serum. But, should either pus or serum be depos- 
ited, then — 

"2. I am sure that evacuation is the proper practice ; and 

" 3. Either should be evacuated per vaginam. 



TREATMENT. V.)l 

"4. The presence of pus in any portion of the body is not to be 
tolerated by the surgeon. I contend that the presence of effused serum 
in the pelvis is not to be tolerated either. As long as it is present in 
addition to the pain and prostration present, there is the abiding stim- 
ulus to repeated inflammations, and the pelvis can and will be ravaged. 

" 5. Topical applications and internal remedies have no influence on 
pelvic and serous effusions, according to my observation." 

For our part, we feel very sure that this subject is one upon which 
no fixed rule can be given. The surgeon must weigh the dangers of 
operation with those of delay, and decide by the indications presenting 
in each individual case. Were the determination of the existence and 
locality of purulent accumulation really as easy at the bedside as one 
might be led to regard it from the literature of the subject, we should 
strongly advocate a uniform resort to evacuation. But this not being 
by any means the case, we are induced to do otherwise. Nor must it 
be imagined that seeking for pus hidden away in the pelvic areolar tis- 
sue is an entirely safe procedure. The following fatal case, due, in all 
probability, to an entrance of air into the veins, will prove interesting 
in this connection : 

"In the case reported 1 aspiration some three months before, for the 
removal of a quantity of pus from the pelvis, had been followed by 
much relief. The symptoms having returned, the needle was again 
introduced through the vagina to the left of the uterus, a distance of 
three-fourths of an inch. As soon as the pumping was commenced the 
patient manifested pain, became convulsed, and grew purple. Conges- 
tion of all the superficial veins followed, though the needle was imme- 
diately withdrawn as soon as the symptoms began, when no more than 
four or five strokes had been made. In three minutes the patient was 
comatose, and in ten minutes the heart ceased to pulsate. 

" The autopsy revealed a small punctured wound on the left side of 
the vagina one and a half inches before its juncture with the uterus. 
The probe passed upward and to the left three-fourths of an inch in the 
direction of a soft tumor in the uterus. Around the track followed by 
the probe was no more than a teaspoonful of clotted blood. A close net- 
work of small veins was traversed by the puncture just outside of the 
vagina, but after the most diligent search it was seen that no important 
blood-vessel had been touched. The areolar tissue about the uterus 
contained air. The left lung was much congested. The right cham- 
bers of the heart were filled with air and contained no blood. The left 
chambers were empty. The valves were normal. The veins of the 
stomach were distended with air, presenting the appearance of pale 
round-worms." 

The Best Point for Evacuation. — To whatever surface the point of 
the abscess is nearest, that will, as a general rule, be the best tor its 
evacuation. If there be a choice, the locations at which it will most 
likely point should be chosen in this order: 1st, the vagina: 2d, the 
rectum ; 3d, the abdominal walls. 

Dr. Savage reports the points of opening, artificial or spontaneous, 
in 19 cases ; they were as follows : 

1 Boston Med. and Sun/. Jottm., vol. cii. No. 17. 



498 PELVIC ABSCESS. 

1 above pubes at median line. 

1 midway between navel and pubes. 

1 outside left saphenous opening. 

2 by rectum — 1 fatal. 

1 by rectum and side of anus. 

1 by colon — 1 fatal. 
4 by vagina. 

2 by bladder. 

1 by iliac region. 

3 into peritoneum — 3 fatal. 

1 by rectum and internal abdominal ring. 
1 by vagina, bladder, rectum, and inguinal region. 
It will be seen that out of 19 cases 5 proved fatal — 3 by emptying 
into the peritoneum, and 2 by causing colitis and rectitis. 

Methods of Operating. — The propriety of opening the abscess having 
been determined upon, the operator, if he intend reaching it through 
the vagina or rectum, should carefully investigate, by touch, as to the 
presence upon their walls of large blood-vessels, the opening of which 
might prove a source of serious hemorrhage. The patient being placed 
on the left side and Sims's speculum introduced, if there exist the 
slightest doubt as to the contents of the sac the needle of a hypodermic 
syringe should be plunged into it and the point decided. If this be not 
done, an ordinary exploring needle should be passed into the tissues 
until pus is seen to flow along its groove. Then the operator, feeling 
sure of his ability to reach pus, holds the needle in one hand, while 
with the other he slides the point of a bistoury along its gutter and 
passes it to the place of accumulation. This is a method at once safe, 
certain, and effectual, and we should recommend it in preference to any 
other except that which comes next to be considered. The aspirator 
affords an easy and effectual means of emptying these accumulations, and 
at the same time one that is to a great extent free from danger. After 
it has removed all the fluid which w x ill flow its action may be reversed, 
the sac filled with warm carbolized water, and this at once drawn off 
again. Should reaccumulation take place, the situation and certainty 
of the purulent collection being established, it may be evacuated by a 
bistoury. If the opening made be large enough to admit the finger, it 
should be passed in, and by it any tract leading into an adjoining- 
abscess should be enlarged, and any sloughing tissue met removed. 
After this, should there be any further closure of the canal just opened, 
its walls may be touched by nitrate of silver or painted with solution 
of persulphate of iron, or a piece of gum-elastic catheter or rubber 
tubing may be left in it. 

In many cases the pus points toward the abdominal skin, and is as 
readily evacuated as from any superficial abscess in another part of the 
body. Only when the pus remains concealed under the firm fasciae of 
the lateral abdominal muscles is a careful and patient dissection advis- 
able and necessary. 

[My practice in cases of this kind has been for years first to satisfy 
myself of the presence of pus by inserting an aspirator needle, guided by 



TREATMENT. 499 

my finger, the patient lying on her back, into the fluctuating mass at a point 
where careful bimanual examination has led me to suspect the presence of 
pus. The vagina of course has been irrigated with a 1 : 5000 solution of 
bichloride, through which indeed I introduce the needle. Pulsating vessels 
are carefully avoided. Having struck a cavity, I withdraw the piston, and, 
finding pus, without removing the needle pass by its side a closed sharp- 
pointed pair of scissors, with which I pierce the walls of the sac, and, having 
entered the latter, separate the blades. A gush of pus shows me that my 
effort has been successful. Keeping the blades separated, I introduce the 
closed blades of a Palmer's dilator, and screwing them apart remove the 
scissors, then introduce my finger and gently scrape the walls of the sac. 
If I find many granulations, I may even use the blunt curette. Now I wash 
out the abscess-cavity with a 1 : 10,000 bichloride solution, and introduce a 
soft-rubber drainage-tube suitably perforated, with a cross-piece at the upper 
end to ensure its retention in the cavity of the abscess. The vagina is then 
loosely packed with iodoform gauze, the drainage-tube closed by a piece of 
tape, and the patient removed to bed. The abscess is irrigated several times 
daily with a tepid 2 per cent, carbolized solution. The gauze is changed 
when it becomes saturated, and the drainage-tube withdrawn as the abscess 
closes. Eventually, the abscess may be kept open until entire closure by 
packing it gently with iodoform gauze every few days. — P. F. M.] 

Means for causing Closure of the Sac. — Sometimes, after the evac- 
uation of these abscesses, their sacs will not close, but, remaining open 
for months and even years, go on pouring out large quantities of pus. 

The causes of their not closing are these : the existence of sinuses, 
which will not allow their complete evacuation ; a peculiar condition of 
their walls from the existence of a membrane, called by Delpech pyo- 
genic, which tends to prolong suppuration ; or the passage into the sac 
of air or feces from the intestines or urine from the bladder. 

Of these the first is decidedly the most frequent, and should be met 
by dilatation of the tract leading to the abscess by tents of laminaria 
or enlargement by the knife. 

Should the abscess have a short and free outlet, the sac should be 
injected two or three times a week with tincture of iodine, at first in 
solution, afterward pure ; or by solution of carbolic acid. 

In case of entrance of feces, air, or urine into the diseased part, a 
counter-opening should be made which will allow their free escape, and 
the part kept as clean as possible by injection of tepid water. Then 
the fecal or urinary fistula allowing the vicarious discharge should be 
cured by appropriate means. 

Before practising any operation for evacuation of pelvic abscesses 
an anaesthetic should always be administered, as perfect quietude is 
essential to safety. 

[Pelvic abscesvses which point toward the abdominal skin, usually in the 
neighborhood of the iliac fossa, will, as a rule, if they have not been allowed 
to remain too long unopened, close very readily under the usual treatment 
of irrigation, packing with iodoform gauze, and, if the granulations are 
indolent, curetting, and the daily introduction of Peruvian balsam or some 
other local stimulant ; but once in awhile the pus has burrowed so deep 
into the pelvic cavity or the opening made was not sufficiently large or has 
not been kept thoroughly distended by the daily dressing, and in eonse- 



500 PELVIC HEMATOCELE. 

quence a sinus has formed which extends deep down into the pelvic cavity 
and obstinately refuses to close. A sound or probe passed down to the 
bottom of the sinus may then often be felt through the vaginal wall or may 
turn off laterally toward the rectum or pelvic wall. Such sinuses are practi- 
cally incurable unless a counter-opening is made into the vagina and thorough 
drainage thus established. My practice has been in such cases to push 
forward the vaginal wall with a stout sound, cut down upon the point of 
the latter, and, after having made a sufficiently large opening, pass a per- 
forated drainage-tube through from the abdominal incision. Thorough daily 
irrigation is then employed, and little by little as the sinus contracts the 
drainage-tube is drawn downward so as to allow the upper portion of the 
sinus to close. A silver wire or a strand of catgut may be substituted for the 
upper portion of the drainage-tube, until this finally is discarded in accord- 
ance with the healing of the upper portion of the track. In this way grad- 
ually the whole sinus may be brought to closure from above downward. It 
is but fair to say that some of these cases prove among the most rebellious 
and tedious ones which it falls to our lot to treat in this locality. On three 
occasions, when drawing the drainage-tube through into the vagina, the 
slight resistance encountered at the new wound in the vaginal wall sufficed 
to produce a rupture of the adherent bladder, as evidenced by the escape of 
urine. The placing of a permanent soft catheter in the bladder, together 
with frequent or permanent irrigation of bladder and wound, served to close 
the rent in a few days, and the patients promptly recovered. I would warn 
operators against making too small cutaneous openings of such abscesses in 
the hope of sparing the patient a large cicatrix. The more thoroughly the 
abscess is opened, cleared out, drained, and its cavity incited to fill up from 
the bottom, the sooner there will be a permanent cure. — P. F. M.] 



CHAPTER XXXV. 

PELVIC HEMATOCELE. 

Definition and Synonyms. — Under this and the synonymous titles 
of retro-uterine hematocele, peri-uterine hematoma, and bloody tumor 
of the pelvis has been described an accumulation of blood in the pelvic 
cavity either above or below the peritoneum. 

[The Germans designate an intra-peritoneal effusion as hematocele, whether 
it be loose or incapsulated ; the intra-peritoneal exudation, however, as hema- 
toma. I confess that I decidedly favor this method of nomenclature, because 
it at once shows the location of the effused blood and to a certain extent 
indicates the proper course of treatment. — P. F. M.] 

History. — Although an attempt has been made to prove that the 
ancients were cognizant of this affection, the proof of such a fact is not 
satisfactory. The earliest allusion made to it is contained in the works 
of Ruysch of Amsterdam, who wrote in 1737. After this little atten- 
tion was paid to it until the time of Re'camier, although mention of it 
was made by Frank, Deneux, and some others. 



PATHOLOGY. 501 

In 1831, Re'camier, under the impression that he was opening an 
abscess, cut into a tumor behind the uterus and gave exit to a large 
amount of black, grumous blood, and about ten years afterward Bour- 
don, one of his pupils, published another case occurring in his practice. 

A tabular view of the names of those who have been chiefly instru- 
mental in elucidating the subject and systematizing our knowledge upon 
it is here presented : 

Recamier, 1831, Lancette franchise ; 

Velpeau, 1843, Richerches sur les Caviies closes; 

Bernutz, 1848, Archives de Medicine; 

Vigues, 1850, Des Tumeurs sanguines de VExcav. pelvienne; 

Nelaton, 1851, Gazette des Hopitaux ; 

Nonat, 1851, These de Cestan, Gallardo, et Prost ; 

Huguier, 1851, Lecture before Surgical Society of Paris; 

Gallard, 1855, Union medicate; 

Voisin, 1858, De I' Hematocele Ritro-utirine. 

We have not endeavored to record the names of all who have made 
valuable contributions in France, for had we done so the list would 
have been a long one. Those only are referred to who have been fore- 
most in advancing our knowledge. 

It will thus be seen that we are indebted to France for the early 
literature of pelvic hematocele. Germany has of later years contrib- 
uted a great deal toward it through the labors of Olshausen, Crede, 
Braun, Hegar, Virchow, Schroeder, Seiffert, and others; and England 
through those of Madge, McClintock, and Tuck well. In America, 
Prof. Gunning S. Bedford reported the first case which we can find 
recorded. More recently we were indebted to Dr. Byrne of Brooklyn 
for a faithful report of several cases. Prior to the year 1851, although 
it had attracted some attention, it was not well understood even in 
France, for in 1850 we find Malgaigne cutting into a hematocele under 
the impression that he was enucleating a fibrous tumor, and losing his 
patient from hemorrhage. 

Frequency. — This subject is not fully settled, a good deal of dis- 
crepancy of opinion existing concerning it. Prof. Olshausen of Halle 
declares that in 1145 gynecological cases he saw 34 hematoceles, and 
Seiffert of Prague reports 66 seen in 1272 cases of pelvic female dis- 
eases. In ten years Dr. Barnes has met with 53 cases, and in twenty 
years Dr. Tilt has seen but 12. 

We do not regard the disease as being by any means very rare, but 
our experience assures us that many cases of cellulitis and a certain 
number of uterine and peri-uterine tumors are reported as those of 
hematocele. 

Pathology. — The definition of hematocele has no relation whatever 
to the cause of the hemorrhage which gives material for the bloody 
tumor. The disease consists in the collection of a mass of blood in the 
pelvis either above or below its roof. Whatever be its source, such a 
collection constitutes the affection which engages us. Ordinarily, we 
find that the flow giving rise to it takes its origin from one of the three 
following sources : 

1st. Direct escape of blood from vessels in or near the pelvis: 
2d. Reflux of blood from the uterus or pubes ; 



502 PELVIC HEMATOCELE. 

3d. Transudation of blood in consequence of dyscrasia or peri- 
tonitis. 

It is evident that hematocele is not a disease, but a symptom of a 
number of pathological conditions. As, however, the source of the 
hemorrhage which results in the bloody tumor very often cannot be 
ascertained, we are forced to deal with its most prominent and sig- 
nificant sign, taking this as an exponent of a state which is beyond the 
possibility of diagnosis. 

In works upon practice written twenty years ago we find dropsy 
treated of as a disease. In those of to-day it is regarded only as a 
legitimate result of renal, cardiac, or hepatic disease. Obstetric wri- 
ters even as late as ten years ago described puerperal convulsions as a 
disease incident to parturition. Those writing ten years hence will 
probably regard them, as many do to-day, as one of the numerous con- 
sequences of renal disease. 

The same was said a few years ago with reference to the disease 
under discussion. At that time the source of the blood in extra- and 
intra-peritoneal hematocele was often uncertain, not being even revealed 
by a careful post-mortem examination. At the present day, chiefly in 
consequence of the frequent performance of abdominal section, it is 
usually not difficult to detect the precise origin of the hemorrhage, and 
often even to check it by the ligation of the vessel from which it pro- 
ceeded. 

The special sources of the hemorrhage, as shown by post-mortems 
in the earlier days and by well-indicated, preconceived laparotomies in 
recent years, may thus be presented at a glance : 

1. Rupture of blood-vessels in the pelvis. 

Utero-ovarian ; 

Varicose veins of broad ligaments ; 

Aneurism of artery ; 

Vessels of extra-uterine ovisac. 

2. Rupture of pelvic viscera. 

Ovaries ; 
Fallopian tubes ; 
Uterus. 

3. Reflux of blood from the uterus. 

Reflux of menstrual blood. 

4. Transudation from blood-vessels. 

Purpura ; 

Scorbutus ; 

Chlorosis ; 

Hemorrhagic peritonitis. 
All of these causes have been proved to have resulted in hematocele, 
but it cannot be questioned that rupture of any blood-vessel which 
empties its contents into the peritoneum might also do so. Blood 
poured into the peritoneum from rupture of the spleen, for example, 
would gravitate toward Douglas's cul-de-sac, because it is the most 
dependent portion of that membrane, and, coagulating, would give all 
the signs of a bloody tumor in that locality. At times the affection is 
indicative of serious internal lesion, rupture of the ovary or tube : at 



CA USES. 503 

others it results merely from imperviousness of the cervical or tubal 
canal, which prevents the advance of menstrual blood and causes it to 
regurgitate into the peritoneum ; while in still a third class of cases it is 
created by the pouring out of blood from the vessels of the peritoneum. 
The last condition has been described as hemorrhagic peritonitis, and 
especially pointed out by Virchow. Schroeder believes that peritonitis 
always precedes the occurrence of hematocele. That it usually accom- 
panies it is unquestionable, but if it be a precursor of this affection, 
which suddenly bursts forth upon a patient apparently in good health, 
it tells badly for our means of diagnosis of pelvic peritonitis. It is 
undeniable, however, that in some cases hematocele does follow and not 
precede the peritonitis. 

Whatever be the source of the blood, it collects either in the most 
dependent part of the peritoneum or in the pelvic areolar tissue beneath 
it. Here it remains for a time fluid, then undergoes partial coagulation, 
becoming a grumous mass like currant jelly, and lastly, all the fluid 
being absorbed, a hard, resisting tumor composed of fibrinous material 
remains. Should the collection have occurred in the peritoneum, its 
boundaries will be the walls of that cavity laterally and below, while a 
localized peritonitis forms for it a roof of effused lymph. If it collect 
in the areolar tissue of the pelvis, the effused blood will make its own 
nidus by percolating the loose structure and mechanically creating a 
space in it. 

In either of these positions it is entirely absorbed and reduced to a 
hard, firm tumor, which remains for a long time or is discharged by the 
vagina or rectum or into the peritoneum. The last point of evacuation 
is fortunately rare. Nonat 1 quotes Dupuytren for the following very 
ingenious and plausible explanation of the method of such absorption, 
which he likens to the process of digestion : The vessels of the cyst 
which are in contact with the mass remove its fluid portion, and thus 
its hard surface comes in apposition with the sac. This excites effusion 
of serum, which softens the fibrinous wall and renders it susceptible of 
absorption, which soon occurs. Then again contact excites a flow of 
fluid, and again this is removed, until the whole mass is diminished or 
completely absorbed. 

Causes. — A glance at the recognized causes of the disease will make 
it evident that congestion of the pelvic organs must, in an eminent 
degree, predispose to it. This explains the fact that it has been found 
to have occurred most frequently during the period of ovarian activity. 
and especially during a menstrual epoch. 

The predisposing causes are — 

The period of ovarian activity, fifteen to forty-five ; 

Disordered blood-state, plethora or anaemia ; 

The menstrual epoch ; 

Chronic uterine or ovarian disease ; 

The hemorrhagic diathesis. 

The exciting causes are — 

Sudden checking of menstrual flow : 
Blows or falls ; 

1 Op. cit., p. 344. 



504 PELVIC HEMATOCELE. 

Excessive or intemperate coition ; 

Obstruction of cervical canal ; 

Obstruction of Fallopian tubes ; 

Violent efforts. 
Varieties. — There are two forms of the affection, subperitoneal and 
peritoneal. In the latter the blood-tumor forms within the peritoneum, 
where it in time becomes encysted, unless death occur at an early 
period. In the former it occurs in the areolar tissue of the pelvis, 
under the peritoneum. 

The propriety of the consideration of the former under the same 
head as the latter has been contested by Aran, Bernutz, and Voisin, 
but from a clinical standpoint it appears to be quite valid. 

[I confess that, from my own individual experience and considering the 
entirely different treatment of the two classes of cases, the separation of the 
intra-peritoneal and extra-peritoneal varieties of hematocele would be most 
useful. I admit that occasionally it is impossible to make an absolute 
diagnosis between the two ; but where this is possible I would submit that 
an extra-peritoneal hematocele should always be opened from below, cleared 
out, and drained through the vagina ; whereas in the case of an intra-peri- 
toneal effusion an abdominal section is invariably indicated. The extra- 
peritoneal hematocele, furthermore, would under such circumstances not be 
a dangerous affection, whereas the other would partake of all the risks 
inherent to laparotomy and the removal of the uterine appendages. While 
I have followed the author's plan of considering these affections under the 
same heading, in order not to disturb too much the original arrangement of 
the chapter, I feel that I owe it to myself and my own convictions to state 
my real standpoint in the matter. — P. F. M.] 

Not only have distinct instances of subperitoneal hematocele been 
recorded by such observers as Simpson, Olshausen, Tuckwell, and 
Barnes ; cases have likewise presented themselves which, commencing 
as subperitoneal ones, have ruptured the peritoneal covering of the pel- 
vis, and thus broken down the theoretical barrier which pathologists 
have been inclined to establish between the two varieties. 

Of the two varieties the peritoneal is much the more frequent, at 
the same time that it is the more grave. In 41 autopsies Tuckwell 
found the tumor to be peritoneal in 38. In a case which I saw with 
Dr. Emmet w T e were unable to make a diagnosis of a tumor which lay 
obliquely anterior to the uterus. [In twenty-four hours the patient fell 
into a state of collapse, and as w T e saw her thus the nature of the tumor, 
which we were doubtful about on the previous day, became evident. 
Upon a post-mortem examination an ante-uterine hematocele as large as 
a goose's egg was found under the peritoneum, through which it had 
broken, discharged a portion of its contents into the peritoneum, and 
caused collapse and death. This is the only ante-uterine, but not the 
only subperitoneal, hematocele with which I have met. — T. G. T.] 

Symptoms. — The absolute occurrence of hemorrhage is generally 
preceded by symptoms which are premonitory, as fixed, dull pain over 
the ovaries, derangement of menstruation,- metrorrhagia or prolonga- 
tion of the menstrual discharge. The symptoms of the actual escape 



SYMPTOMS. 

Fro. 230. 



505 




Intraperitoneal Hematocele (Barnes). 
Fig. 240. 




Extra-peritoneal Hematocele (Emmet). 1 



of blood will depend in great degree upon the nature and gravity of 
the accident which has given rise to it. 

Sometimes the affection occurs without any violent symptoms and 
almost without warning. It will be appreciated that this would be so 
if it were due to gradual reflux of blood on account of constricted 

1 Both these diagrams might be used to illustrate respectively an intra-peritoneal 
plastic exudation in acute pelvic peritonitis, and an extra-peritoneal effusion of the 
same material in pelvic cellulitis. 



506 PELVIC HEMATOCELE. 

cervix, or transudation the result of purpura. Frequently a sudden 
manifestation of symptoms occurs, and the accident is announced as 
rapidly as is cerebral apoplexy. 

It is evident, then, that the symptoms must differ widely in cases 
marked by very great and sudden loss of blood and those accompanied 
by very little. In the first there are evidences of profuse abstraction 
of vital fluid, great peritoneal shock, and excessive prostration. In 
the second these may all be so slight as to escape the notice of non- 
observant patients. The best course which can be pursued in reference 
to the matter is, we think, to take as an example a case of moderate 
severity, and guard the reader against supposing that all attacks give 
the same degree of intensity of symptoms. 
Most prominent among the symptoms are — 

Severe pain in the pelvis ; 

Pallor, faintness, and coldness of extremities ; 

Sense of exhaustion ; 

Nausea and vomiting ; 

Metrorrhagia ; 

Uterine tenesmus ; 

Tympanites ; 

Interference with bladder and rectum ; 

Small and rapid pulse ; 

Depressed thermometric range. 
The patient feels as if a large and heavy body exists in the pelvis, 
and instinctively strives to expel it by the vagina. At times the pain 
complained of is very acute ; at others it is a dull and heavy aching. 

After a variable time, generally within forty-eight hours, a reaction 
from this state of prostration occurs. Sometimes this is slight, at others 
decided. It is dependent chiefly upon the degree of inflammation set 
up by the sanguineous accumulation acting as a foreign body. This is 
usually marked by the following symptoms : 

Tendency to chilliness ; 

Constipation ; 

Suppression of urine ; 

Great tympanites ; 

Heat of skin ; 

High thermometric range ; 

Rapid pulse ; 

Tenderness over abdomen. 
All these symptoms point to three facts : 1st, sudden and excessive 
loss of blood : 2d, the existence of some substance in the pelvis which 
mechanically interferes with its viscera ; 3d, the presence of a local 
inflammation causing the high temperature and produced by the sudden 
irritation of a foreign body, the effused blood. A part of them might 
be produced by menorrhagia, a part by sudden retroversion, but a 
union of the whole will strongly excite suspicion of hematocele and call 
for a physical exploration. 

Physical Signs. — Vaginal touch reveals a tumor usually posterior 
to uterus and vagina, and generally partially closing the latter. The 
mass thus felt, if the examination be made verv soon after its formation, 



DIFFERENTIA TION. 507 

will be found to be soft, smooth, and obscurely fluctuating. If a num- 
ber of days have elapsed before it be touched, it will give the impression 
of a smooth, dense, solid body. The uterus will be found pressed out 
of its position, generally upward and forward, so that the cervix will be 
above the symphysis. Sometimes, though rarely, it is forced out of 
the median line to one side. 

Nonat 1 dogmatically announces that the uterus is never found 
between the tumor and the rectum — that is to say, behind the mass 
of blood; but Chassaignac 2 reports a case in which the sanguineous 
collection existed entirely between the bladder and uterus, and con- 
sequently must have forced that organ backward ; and similar cases 
are recorded by G. Braun, Olshausen, Barnes, Emmet, Thomas, and 
others. 

Rectal touch will show that the bowel is partially closed by pressure 
from the tumor. 

Abdominal palpation will reveal the presence of a hard mass which 
may extend only up to the superior strait or as high as the navel. In 
cases where a small quantity of blood has been effused, and more espe- 
cially where this has collected under and not in the peritoneum, an 
abdominal tumor may not be discovered. 

By the aid of conjoined manipulation the shape, extent, and charac- 
ter of the mass may be further ascertained. 

Differentiation. — The diseases with which hematocele may be con- 
founded are — 

Pelvic cellulitis or abscess ; 
Retroversion ; 
Extra-uterine pregnancy; 
Fibrous tumor ; 
Dislocated ovarian cyst. 

The mass created by cellulitis and abscess is usually found at the 
side of the uterus, and not posterior to that organ ; it develops less 
suddenly than hematocele ; is hard at first, and gradually softens ; is 
exquisitely painful to touch ; does not lift the uterus and press it for- 
ward; and is not usually accompanied by metrorrhagia. 

Retroversion may present the signs due to the mechanical results of 
hematocele, but not those due to loss of blood. If pregnancy coexist, 
conjoined manipulation will usually suffice for diagnosis. If it should 
not, the uterine probe will elucidate the case. 

Extra-uterine pregnancy does not develop suddenly, but slowly, and 
is characterized by many of the signs of pregnancy. In place of 
metrorrhagia there is usually, though not always, amenorrhea. 

Fibrous tumors grow slowly, are painless, and move with the uterus. 
They are irregular and hard, and do not usually push the uterus so far 
forward and upward. 

Displaced ovarian cysts are painless, show no signs of hemorrhage, 
and cause no constitutional disturbance or metrorrhagia. 

Course, Duration, and Termination, — Hemorrhage from the sources 
enunciated as those of hematocele may be so great as to destroy life 
immediately. Five such instances are recorded by Voisin, and Ollivier 
1 Op. cit, p. 34-2. '-• Court y, Mai de I'Utirus, p. 912. 



508 PELVIC HEMATOCELE. 

d' Angers 1 mentions two in which death occurred in half an hour from 
rupture of a varicose utero-ovarian vein. Such a termination is, how- 
ever, decidedly exceptional. The tumor generally disappears by absorp- 
tion, is discharged by the rectum or vagina, or remains a hard, indu- 
rated mass long afterward. Discharge is most frequently followed by 
recovery, but sometimes putrefaction occurs in the walls of the sac, 
septicaemia takes place, and death ensues. The process of absorption 
may be accomplished in three weeks, or six months may elapse before 
it is complete. 

In some cases a slow and steady hemorrhage appears to go on for 
weeks and render the bloody tumor gradually larger. In others hem- 
orrhages subsequent to the first take place after this has become encap- 
sulated. After subsidence of the symptoms of reaction, chill, fever, 
and sweating often come on late, marking suppuration in the mass and 
slight septic absorption. 

Prognosis. — The prognosis of hematocele must be governed in great 
degree by the amount of blood lost, the degree of constitutional shock 
resulting, and the intensity of reaction excited. As a rule it is favor- 
able — especially so, Ave should say, when treated upon the expectant 
plan, and not by immediate surgical interference. 

In cases of peritoneal form a graver prognosis is called for than in 
the subperitoneal, for evident reasons ; and where a great deal of blood 
has been lost the dangers are greater than where the amount has been 
more limited. This is true not only from the fact that an excessive 
flow might cause death from exhaustion, but because the removal of so 
large an amount of coagulum, whether by absorption or discharge, must 
necessarily expose the patient to great dangers. 

When death occurs it is usually a consequence of loss of blood, shock 
from sudden invasion of the peritoneum, peritonitis, rupture of the 
encapsulated mass into the peritoneum, or septicaemia. 

Treatment. — The physician will rarely be called upon to resort to 
treatment before the amount of blood which is destined to be lost has 
collected in the pelvis. He will, however, often be present to witness 
the great constitutional disturbance and excessive prostration and pain 
which immediately follow the hemorrhage. The diagnosis being made, 
the indications for treatment will be simple enough : 
1st. To check tendency to further loss ; 
2d. To prevent death from prostration ; 
3d. To relieve pain. 

[As already referred to, the treatment of the two forms of pelvic hema- 
tocele, the intra-peritoneal and the extra-peritoneal, differs most markedly. 
The presence of a certain amount of blood in the peritoneal cavity means 
the rupture of a vessel inside of that cavity from which an unlimited sup- 
ply of the vital fluid may escape, sufficient indeed to produce speedy or 
immediate death. The rupture of such a blood-vessel should be treated on 
the same principle as the escape of blood from an artery or vein in any 
other portion of the body — namely, by an immediate exposure and ligation 
of the vessel. If, therefore, we have good and sufficient reason to suspect 
that the rupture of a blood-vessel, be it vein or artery, of sufficient size to 

1 Noeggerath, Bid. N. Y. Acad. Med., vol. i. p. 577. 



TEE A TMENT. 509 

be serious, lias taken place within the peritoneal cavity, no matter where 
the bleeding vessel may be situated, in the light of our present experiences 
it seems our duty to open the abdominal cavity, expose and ligate that 
vessel, and thus by the only certain means in our power arrest the hemor- 
rhage. The urgency of the adoption of this plan depends mainly on the 
capacity of the abdominal cavity for holding a quantity of effused blood 
sufficient to cause the death of the patient. 

With the pelvic cellular tissue, however, the case is entirely different. 
Its capacity for holding an effusion of blood is certainly limited, at least for 
the time being. The meshes of cellular tissue, the natural cohesion of the 
various organs occupying the pelvic cavity, the difficulty of dissecting up 
the peritoneum in order to make room for the effused blood, — all these 
obstacles will naturally prevent the exudation of more than a limited amount 
of blood during a certain period of time. Hence there does not arise the 
necessity for immediate action to arrest the hemorrhage, since it to a certain 
extent tends to control itself. For this reason the directions contained in 
the following lines are to be carried out, but [I wish it understood that in 
my opinion they apply almost exclusively to cases of extra-peritoneal effu- 
sion of blood.— P. F. M.] 

These indications should, as far as possible, be met simultaneously, 
for the dangers to be combated all occur at one and the same moment. 
The patient should at once, without the delay attendant upon changing 
the clothing, etc., be put in a condition of perfect rest, and a full dose 
of morphia be administered hypodermically. A bladder of crushed ice 
or cloths wrung out of iced water should be laid over the hypogastrium, 
and bottles of hot water or warm bricks wrapped in flannel should be 
put to the soles of the feet. Should the stomach not be very irritable, 
brandy and water or iced champagne should be given freely by the 
mouth. 

If prostration be so alarming as to threaten collapse, and the stom- 
ach be intolerant of ingesta, brandy or sulphuric ether in doses, the 
former of tw T o drachms, and the latter of half a drachm, should be 
injected subcutaneously by the hypodermic syringe. 

Reaction having taken place, the most perfect quietude should be 
observed, pain should be relieved and nervous shock prevented by the 
free use of morphine, and the diet should consist of milk, animal 
broths, and gruels of farina, sago, or Indian meal. 

And now will arise the important question whether the accumulated 
blood should be left for removal by nature or should be evacuated by 
surgical means. Recamier, in introducing the subject to the profession, 
inaugurated the practice of evacuating such tumors, and Nelaton 
endorsed and popularized it. But experience taught Ne'laton that the 
procedure was not judicious, and " to-day he proscribes it in an almost 
absolute manner." Immediate surgical interference presses its claims 
in consideration of the facts that — 

1st. It is capable of cutting short a lengthy and dangerous disorder ; 

2d. It may save the patient from the dangers incident to absorption 
as well as discharge. 

3d. It removes from the pelvic cellular tissue a foreign body which. 
undisturbed, would prove the focus of inflammation. 

It is not surprising that it was the favorite plan in the infancy of the 



510 PELVIC HEMATOCELE. 

subject. When, however, pathologists had had an opportunity of study- 
ing the natural history of the affection, it was as naturally abandoned, 
for the following reasons : 

1st. It was discovered that when not interfered with, extra-peritoneal 
hematocele very generally passes away rapidly. 

2d. It was discovered that the dangers of puncture were greater 
than those of the tumor left undisturbed. 

3d. Medical means were found to exert a marked controlling influ- 
ence over its complications. 

With the light which experience has thrown upon this point it 
appears to us that, without being dogmatic, we may safely adopt this 
rule: If, as time passes, suppuration within the sac, which has then 
pretty certainly become encapsulated, and septic absorption are mani- 
fested by chills, febrile action, and profuse sweating, the softening mass 
should be discharged by incision. In other words, so long as the accu- 
mulated blood appears to be doing no decided harm and nature seems 
to be causing its absorption, it should be left alone. But so soon as 
evidences of septicaemia are observed it should be evacuated. Under 
these circumstances a neglect of surgical interference would be culpable. 

[There are two other reasons why such extra-peritoneal effusion of blood 
may in rare instances call for evacuation — namely, first, where the amount 
of effused blood is so large that after a month or more of patient waiting no 
signs of absorption manifest themselves. There is no evidence of purulent 
degeneration or of septic infection, but the patient is not improving, the 
pelvic tumor does not change in size or in consistence, except that it is 
becoming a little softer perhaps, and naturally all parties concerned are 
anxious to have the case cured. Second, where a succession of fresh effu- 
sions of blood take place, each of course increasing the size of the pelvic 
tumor and debilitating the patient still more. In the first instance it is useless 
to wait for nature to effect the absorption of a mass of fluid or coagulated 
blood amounting to perhaps as much as from two to three pints. By open- 
ing the sac thoroughly through the vagina, clearing out its contents care- 
fully, irrigating it, and packing it with iodoform gauze, repeating this latter 
procedure as often as appears indicated, a speedy shrinking of the sac, its 
early closure, and rapid recovery of the patient will almost inevitably result. 
In the second case it is evident that the blood itself does not act as a sufficient 
hemostatic agent to prevent further hemorrhage, and that firmer pressure is 
required against the blood-vessels to effect this purpose. We therefore, while 
perfectly conscious of the risk which we take in opening a cavity portions 
of which are still liable to bleed, adopt this plan, being fulty prepared to 
check any hemorrhage which may occur after the cavity is evacuated. This 
is done very readily by packing the cavity tightly with iodoform gauze, 
which can be safely left in situ for as long as a week even without becoming 
offensive, and upon removal the bleeding spots will undoubtedly be found to 
have healed. The treatment of the sac is then as already indicated. I 
have operated on at least a dozen such cases, evacuated up to two quarts 
of fluid and coagulated blood, in every instance with perfect and speedy 
cure. 

I am aware that some authors favor the operation of extra-peritoneal 
hematocele by means of abdominal section, opening the sac covering the 
effused blood — that is to say, the distended broad ligament — sewing its 
edges to the abdominal wound, and treating it like an intra-ligamentous. 



TREATMENT. 511 

non-removable ovarian cyst. I have operated in this manner several times, 
I confess in consequence of a mistaken diagnosis as to the intra- or extra- 
peritoneal location of the blood. T have been fortunate enough to cure my 
cases, but with vastly more labor to myself and danger to them than by the 
method of vaginal opening. In one case, after opening the abdominal cavity 
and finding the distended broad ligament so tense as to prevent its attach- 
ment to the abdominal wall, I closed the incision and opened the hematoma 
by the vagina, with the result of a speedy recovery. 

In cases where the extra-peritoneal hematoma extends up into the iliac- 
fossa and forms a tumor palpable through the abdominal wall, some opera- 
tors have preferred to make an incision very similar to that practised in 
opening a perityphlitic abscess, and have thus entered the cavity containing 
the effused blood without interfering with the peritoneal cavity. I can see 
no special advantage for this method of operating over that through the 
vagina, unless the evacuation of the blood happens to be difficult from below. 
In one case under my observation, which was operated on by another sur- 
geon after my retirement from the case, it was found necessary, by the 
surgeon's own statement to me, to open the sac from the vagina in addition 
to the abdominal incision ; which latter, I think, could have been entirely 
avoided in the case under consideration. — P. F. M.] 

Methods of Operating. — The patient being placed upon the back, as 
if for lithotomy, a trocar and canula may be held in the right hand, 
guided to the most fluctuating and dependent part of the mass, and 
plunged in. Or, the patient lying on the left side, the perineum and 
posterior vaginal wall may be lifted by Sims's speculum, and an incision 
made into the wall of the tumor by a tenotomy knife or small bistoury. 
Through the opening thus made one or two fingers should be introduced 
and the clots removed. After evacuation by either method the nozzle 
of a syringe should be introduced into the sac, and a stream of tepid 
water, with or without a very small amount of carbolic acid, should be 
very gently and cautiously made to w r ash out the cavity remaining. 
This should be repeated once or twice in twenty-four hours for preven- 
tion of septicaemia. All this should, as far as possible, be done under 
the antiseptic method. 

After the abatement of acute symptoms a blister, four by six inches, 
should, unless some contraindication exists, be applied over the hypo- 
gastrium, and this may with advantage be repeated every ten or twelve 
days. Its results will often be very marked, and, although apparently 
harsh practice, it prevents much suffering, while it causes but little. 

As time passes and pain is relieved, quinine, alone or combined with 
sulphuric acid, in full doses will prove a valuable remedy, and should be 
kept up perseveringly. 



33 



512 FIBROID TUMORS OF THE UTERUS. 



CHAPTER XXXVI. 

MYO-FIBKOMATA, OK FIBKOID TUMOKS OF THE UTEEUS. 

Definition and Synonyms. — The parenchyma of the uterus is liable 
to undergo a localized hypertrophy, which results in the production of 
two varieties of tumors — the fibrous and the fibro-cystic. The first, 
which is one of the most frequent pathological conditions to which this 
organ is subject, will now receive attention, while the second and much 
rarer form will be treated of in a separate section. 

By the. older writers fibrous tumors were styled tubercula, steatomata, 
sarcomata, etc. Since their true nature has been more carefully studied 
by aid of the microscope and been understood, they have been described 
under the name of fibrous tumors, uterine fibroids, fibroma, and more 
recently, by Virchow, myoma. We have adopted the terms which head 
this chapter, following the example of Billroth for the first, and of Klob 
for the second, for the reason that neither that of fibroma nor myoma 
alone expresses the existing pathological condition. Billroth 1 rejects 
the latter name, which signifies that these growths consist in hyper- 
trophy of muscular substance, and at the same time he refuses to admit 
the former, as that conveys the equally incorrect idea that they are con- 
structed of connective tissue. Fibroid (fibrosus and etdoz), resembling 
fibrous tissue, is at least not calculated to mislead, while myo-fibroma 
expresses the exact truth. 

History. — Until the time of Dr. William Hunter, who wrote toward 
the close of the eighteenth century, the true nature of uterine fibroids 
was not appreciated. They were confounded with malignant growths, 
of which they were regarded as a variety. He described them under 
the name of fleshy tubercle, and contributed greatly to the knowledge 
of their pathology ; but it was not until the writings of Chambon, 2 
Baillie, Bayle, and others that the subject was fully elucidated. Sir 
Charles Clark in 1814 wrote an excellent chapter upon them, which 
would almost answer the requirements of our day. 

Pathology. — Surprise that any confusion should have existed be- 
tween these tumors and cancerous growths will cease when we consider 
that their identity is boldly assumed by so careful an observer as Dr. 
Ashwell as late as 1844. He gives five reasons for his belief which 
he declares appear to him "conclusive." His reasoning has failed to 
convince others, no writer since his time having adopted the view 
which Dr. Hunter succeeded in abolishing, and no fact in gynecology 
is now more fully settled than that of the non-malignancy of these 
tumors. 

We mention the above belief merely as a matter of ancient history. 
Since our own personal earliest recollection there has been at no time 

1 Surg. Pathol, p. 583. 2 Mai. de V Uterus. 



PATHOLOGY. 513 

a question as to the benignancy of fibroid tumors. That they may 
occasionally, although very rarely, gradually change their composition 
and become malignant can, unfortunately, not be denied. 

Bayle and Lobstein have declared that they never undergo cancer- 
ous degeneration, and the researches of Cruveilhier and Lebert tend 
to support the view ; while Kiwisch, Dupuytren, Atlee, 1 and Simpson 
believe that malignant degeneration occurs in rare cases. The weighty 
authority of Virchow 2 is cast into the scale favoring the possibility of 
both carcinomatous and sarcomatous degeneration, and Klob agrees in 
this assertion. "In 1862," says the latter author, " a singular speci- 
men was added to the Salzburg Museum. From a fibroid tumor the 
size of a child's head, situated in the posterior walls of the uterus, car- 
cinoma had undoubtedly been developed without any other portion of 
the body being affected ; and I am therefore constrained to allow the 
possibility of such a transition, although I cannot recall a second case 
of this kind either in the literature of the subject or in my rather 
extensive experience." 

Although this case seems to settle the matter of possibility at least, 
it must not be forgotten that beyond doubt such a change of type is 
exceedingly rare. It is in this connection a fact worthy of note that 
in the negress, in whom fibroid tumors are so common as to be regarded 
by some as almost universally met with after the thirtieth year, carci- 
nomatous affections of the uterus are very rarely seen. 

[Within the past year I have met with a case of a large subperitoneal fibroid 
in which the diagnosis was absolutely assured, and, there being no constitu- 
tional symptoms whatever, where I practised vaginal galvano-puncture six 
times with a negative result. Nine months after she had left my private 
hospital for her home in the West I received a letter from her husband, a 
physician, informing me that she had died of malignant sarcoma, the dia- 
gnosis being made by one of our most eminent specialists in a neighboring 
city. Curiously, she had become pregnant in spite of the tumors, and died 
a week after the induction of premature labor from the exhaustion attend- 
ing the malignant growth. I have no question that the malignant degenera- 
tion set in long after she left my care. Whether the electro-puncture had 
anything to do with this I must leave a matter of doubt. — P. F. M.] 

[I have met with two cases in which uterine fibroids which had been 
known to exist for eight and ten years, and had behaved like benign growths, 
suddenly took upon themselves the aspect of sarcoma and led to a fatal 
termination. In one case the tumor was removed post-mortem, and in the 
other ante-mortem with great relief to symptoms. — T. G-. T.] 

Uterine fibroids may develop singly, when ordinarily they do not 
attain to a very great size. Sometimes, however, they exist in great 
numbers and grow to a very large size. Courty reports one weighing 
fifty pounds [and I have removed one, with uterus and both ovaries, 
of the same weight. Some years ago I exhibited to the New York 
Pathological Society the uterus of a negress which contained thirty-five 
tumors 'of every size between that of a foetal head and that of a mar- 
Me.— T. G. T.J 

Fibroids may develop in any part of the uterus, but the usual site 
1 McClintock, Diseases of Women. 2 radiologic des Tumettrs. Paris. 1871, 



514 FIBROID TUMORS OF THE UTERUS. 

is in the body or fundus. Mr. S. Lee examined seventy-four prepa- 
rations in the London museums, and found that the rarest of all loca- 
tions for them is the cervix. A very interesting instance of a large 
tumor developed below the os internum is reported by Dr. Murray in 
the sixth volume of the London Obstetrical Transactions. [I have 
myself removed several of this character from the parenchyma of the 
cervix, the body of the uterus being in no wise involved. — T. G. T.] 

[The largest cervical myoma which I had occasion to remove was one 
weighing three pounds, and situated in the anterior wall of the uterus and 
lip of the cervix, which filled the pelvic cavity so completely as to render 
the delivery of the woman, who was six months pregnant when she came 
under my care, absolutely impossible. I removed the tumor by enucleation 
per vaginam. and then delivered the woman. She made an easy recovery. 1 
Two years later I removed another cervical myoma from the same woman, 
which had developed and grown down since the previous operation. — 
P. F. M.] 

The structure of fibroid tumors varies very greatly, not only from their 
original development being different, but from their being susceptible of 
several diseased states, which will very soon be mentioned, and which 
produce their characteristic alterations. The typical form is that of hard, 
resisting fibrous tissue, which creaks under the knife. Lender the 
microscope this is found to consist of long, fine fibres generally united 
in bundles, of fusiform fibre-cells analogous to fibro-plastic elements. 
and of round or elliptic granules of small size, the whole being bound 
together by fine intercellular substance. 

They consist of the hypertrophied elements of the uterus, to which 
organ they are strictly homologous. In the majority of cases it is 
declared by recent pathological investigators that connective tissue pre- 
ponderates in their construction, but there is always a certain degree 
of muscular hypertrophy concerned in their development ; hence Bill- 
roth's objection to the terms "fibroma" and ' k myoma." In some 
cases the amount of muscular exceeds that of connective tissue in their 
construction. This, which may be styled the normal type of the ute- 
rine fibroid, is departed from by formation of cysts in the midst of the 
fibrous tissue, which constitutes the tumor one of fibro-cystic character. 

Uterine fibroids are liable to a variety of diseases, among which the 
most frequent are oedema, inflammation, gangrene, cystic, fatty, and 
calcareous degeneration, and apoplexy. The last consists in rupture 
of small blood-vessels within the mass, and consequent accumulation 
of blood. 

Very rarely the whole mass becomes a ball of calcareous matter, 
which, projecting in utero and becoming detached, is sometimes dis- 
charged per vaginam. This is the disease which was described by old 
writers as uterine calculus. The uterine attachment of fibroids of com- 
pound character is sometimes the seat of a species of varicose degen- 
eration of the small vessels, which causes the structure to resemble 
erectile tissue. Tumors thus affected have been styled by Virchow 
telangiectatic tumors. This vascular structure readily bleeds, and in 

1 Amer. Gynecol. Trans., 1884. 



PATHOLOGY. 

Fig. 241. 



515 




Uterine Fibroma : Oblique Longitudinal Section of Muscular Cell-bundles (Billroth). 

one case we saw it the cause of a small hematocele. But large vessels 
are likewise discovered in the pedicles of fibroids, Caillard reporting 

Fro. 242. 




Section of a Large Fibroid Tumor, with Fibres arranged around Several Centres (Sutton). 



one the size of the radial artery. Klob has met with but one such 
vessel, which was the size of the uterine artery. 



516 



FIBROID TUMORS OF THE UTERUS. 



Varieties. — Klob divides these growths into two classes — simple 
and compound. The first consists of one tumor, which is generally 
spherical, and which is connected by loose connective tissue with the 
uterus. The second is a compound tumor, made up of a number of 
small fibroids connected by loose connective tissue. The second variety 
is more vascular than the first, and its surface is nodulated and not 
smooth. Both these classes present themselves clinically in three varie- 
ties, which are created by the locality of the growths in the walls of 
the uterus. If they lie under the mucous membrane projecting into the 

Fig. 243. 




Large Subperitoneal Fibroid Tumors, one in the Anterior and the other in the Posterior Wall 

of the Uterus. 



uterine cavity, they are called submucous ; if under the peritoneum, 
subserous ; if in the wall of the uterus, interstitial. 

If a tumor be situated in the wall of the uterus, it may remain 
there until it assumes large dimensions. Should it be near the mucous 
or serous lining, it is subjected to contractile efforts on the part of the 
surrounding parenchyma which are excited by its presence, and which 
often in time force it toward the uterine or abdominal cavity. Some- 
times its connection with the mother-tissue is kept up by a broad base ; 
sometimes it is limited to a long, slender pedicle, which in the case of 



VARIETIES. 



517 



the subperitoneal varieties allows of great mobility. Should the mass be 
forced into the uterine cavity, and gradually assume a slender, pedun- 



Fig. 244. 



Fig. 245. 




Subperitoneal Fibroid. 



Interstitial Fibroid. 



culated attachment, it receives the name of fibrous polypus, which is 
therefore a variety of submucous fibroid. 



Fig. 246. 



Fig. 247. 




Pediculated Subperitoneal Fibroid 



Pediculated Subperitoneal Fibroid. 



These neoplasms often affect the uterus very curiously. The inter- 
stitial varieties produce every form of displacement : the submucous 
sometimes produce complete inversion of uterus and vagina : and the 
subperitoneal, Virchow declares, by dragging the fundus upward not 



518 



FIBROID TUMORS OF THE UTERUS. 



only draw out the cervix so as to make it resemble the urethra, but 
absolutely cause " the spontaneous separation of the neck from the 



Fig. 248. 




Interstitial Fibroid Tumor. 



body of the uterus." The last variety, too, sometimes shows most 
singular migrations. The pedicle being broken, they have at times 



Fig. 249. 



Fig. 250. 




Small Submucous Fibroid with Broad Ses- Large Submucous Fibroid with Broad Sessile 

sile Attachment. Attachment. 

(Suitable for removal by enucleation and traction, or by morcellement, after dilatation of the 

cervical canal.) 



CA USES— CO MPL TCA TIONS. 



519 



been found rolling about freely in the peritoneum, and at others, hav- 
ing set up adhesive inflammation, they have been found detached from 
the uterus and attached to some other abdominal viscus. 



Fig. 251. 




Fibroid attached to Posterior Lip of Cervix (simulating a polypus). 

Causes. — The predisposing causes, or rather those generally regarded 
as such, are — 

, Race, the African being peculiarly liable ; 

Age, from thirty to forty-five ; 

Nulliparity ; 

Menstrual disorders of long standing. 
Concerning the exciting causes, one writing m the year 1891 may, 
unfortunately, quote the words of Sir Charles Clark, recorded in 1814 : 
"Nothing is known respecting the cause of this disease." Nearly 
eighty years of research have thrown no light upon its etiology. 

Complications. — The most frequent of the complications which show 
themselves in the course of the disease are — 

Endometritis ; 

Displacements ; 

Cystitis ; 

Obstruction of the rectum ; 

Hemorrhoids ; 

Pelvic peritonitis ; 

Areolar hyperplasia ; 

Atrophy of uterine walls ; 

Grave menstrual disorders. 
Every one who has made autopsies upon cases in which uterine 
fibroids have existed must have been struck by the fact of the varied 
appearance of the walls of the uterus. Where several tumors exist the 
uterine cavity is sometimes so perverted and rendered so tortuous that 
it cannot be traced, while in cases where a large number of tumors are 



520 FIBROID TUMORS OF THE UTERUS. 

formed the whole uterus seems to have disappeared, its place being 
usurped by tumors. [In the case already cited, in which I counted 
thirty-five tumors, no trace of the uterus could be discovered by the 
naked eye above the os internum. — T. G. T.] In some cases the vice of 
nutrition set up by the presence of these growths results in thickening 
of the uterine walls by the establishment of interstitial hypertrophy, in 
others localized points of thickening exist, while in others still the wall 
of the uterus may become so attenuated by distension and atrophy as to 
leave only a thin film to represent it. This distended and attenuated 
organ is that which Walter has styled the " membranous uterus." 

Symptoms. — The enumeration of complications just given is a suf- 
ficient explanation of the great number of rational signs which present 
themselves, for not only do we meet with the symptoms of fibroid 
tumors, but with those of a variety of disorders which they excite. 
Most prominent among the symptoms are — 
Menorrhagia or metrorrhagia ; 
Irritability of bladder and rectum ; 
Pain throughout the pelvis ; 
Uterine tenesmus ; 
Profuse leucorrhcea ; 
Dysmenorrhea ; 

Signs of pressure on crural nerves and vessels ; 
Watery discharge from uterus. 

These symptoms are not equally common to the three varieties of 
the affection. Subperitoneal tumors often, and interstitial tumors 
sometimes, are accompanied by none, or at least by very few, of them. 
It is the submucous variety which most constantly and prominently 
develops them. 

The immediate effects of uterine fibroids are exerted upon the sys- 
tem through the following means : 

1st. They produce excessive menstrual discharge and profuse leucor- 
rhcea, which impoverish the blood ; 

2d. They press upon and derange the innervation of neighboring 
parts ; 

3d. They in some way interfere with hematosis and the functions of 
the ganglionic nervous system ; 

4th. They disorder the mind by creation of depression of spirits, 
from the fact that the patient recurs with gloomy apprehension to their 
existence almost constantly. 

Physical Signs. — Although the rational signs are so numerous and 
striking, they can never do more than excite a suspicion, which leads 
to investigation by physical means. 

In the case of a large tumor no difficulty in diagnosis will present 
itself; for the results of vaginal touch, abdominal palpation, and con- 
joined manipulation will be so decided as to settle the character of the 
case definitively. When, however, a growth of small size exists, great 
difficulties will often attend diagnosis, which may be delayed until the 
case has been under observation for a long time. A thorough exami- 
nation involves full and careful exploration by touch of the anterior 
and posterior surfaces of the uterus, as well as of its cavity to the fundus. 



DIFFERENTIATION. 521 

To examine the external surfaces of the uterus the patient should 
lie upon the back with the thighs flexed. All constriction should be 
removed from the waist and the bladder and rectum emptied. The 
examiner then, depressing the uterus by the right hand placed over the 
hypogastrium, should sweep the index finger of the other as high up as 
possible over the posterior wall, first by vaginal and then by rectal 
touch. While the finger in the vagina or rectum lifts the uterus, the 
tips of the fingers placed on the abdomen should be forced behind the 
fundus and downward over the posterior uterine wall, so as to approach 
the finger within the pelvis. By these means the posterior wall will 
be superficially examined in women with tense abdominal muscles, 
thoroughly in those in whom they are thin and relaxed. 

The finger in the vagina now drawing the cervix forward, the fin- 
gers of the hand on the abdomen should be made to depress its walls 
so as to sweep from the fundus over the anterior surface down to the 
cervix. The finger under the cervix, lifting it up, will offer itself as 
an opposing force to the hand on the abdomen. This manoeuvre will 
fully expose to examination the anterior surface of the uterus unless 
the patient be very fat. Should she be so, a tenaculum may be fas- 
tened in the cervix and the uterus drawn down by it, so that the pos- 
terior wall will be better within reach of rectal touch, and the anterior 
wall within that of vaginal exploration when the finger is pressed firmly 
against the base of the bladder. 

For investigating; the interior surface of the uterus the neck should 
be fully dilated by tents, and immediately upon their removal, the ute- 
rus being depressed as for examination of the outer surface, the finger 
should be carried into the cavity of the body. 

Differentiation. — The diseases which may be confounded with 
fibrous tumors are — 

Pregnancy ; 

Para-uterine cellulitis ; 

Pelvic hematocele ; 

Anteflexion or retroflexion ; 

Ovarian tumors ; 

Fecal impaction. 
In pregnancy, amenorrhoea and other signs of utero-gestation exist, 
while in uterine fibroids there is usually a tendency to menorrhagia. 
In pregnancy the uterus is symmetrical, in fibroids usually asymmetri- 
cal. The tumor found in pregnancy is generally softer than in fibroids, 
and more uniformly median in position. In a doubtful case time, with 
its development of foetal movements, will always settle the point. It 
should not be forgotten that pregnancy and fibroids may occur together, 
the recognition of the tumor being rendered more difficult by the 
softening always produced in such growths by pregnancy. A point in 
aid of a correct diagnosis is the increased size of the uterus, out of 
proportion to the supposed time of gestation, as well as its irregular 
shape. 

The tumor created by cellulitis is immovable, very sensitive, accom- 
panied by fever, comes on suddenly, and fixes the uterus. A fibroid 
tumor is the opposite of this in every respect. 



522 FIBROID TUMORS OF THE UTERUS. 

Hematocele generally occurs suddenly and with violent symptoms. 
The tumor is sensitive and immovable, at first semifluid, and accom- 
panied by tympanites and constitutional disturbance. Fibroid tumors 
show no such symptoms. 

Flexion may be determined by the uterine probe, and differentiation 
established between it and fibroids by conjoined manipulation and rectal 
touch. 

Ovarian tumors of solid form are the only ones which usually give 
difficulty in diagnosis, and these are rare. They are accompanied by 
menorrhagia, can be pushed from side to side without affecting the 
position of the uterus as ascertained by vaginal touch, and are less 
affected by movement of the uterus by means of the uterine sound. 
In cases where an ovarian tumor is firmly attached to the uterus differ- 
entiation is not only difficult, but often impossible. 

Fecal impaction presents a tumor which can often be indented by 
pressure, is generally in the caput coli, does not move with the uterus, 
gives severe intestinal pain and disorder, and exerts little influence on 
the functions of the uterus. 

From this rapid disposal of the subject of differentiation it must not 
be supposed that it is always an easy matter. In many cases only 
careful watching will enable the diagnostician to arrive at a certain 
conclusion. 

Prognosis. — The practitioner cannot be too cautious or display too 
much reticence in pronouncing the prognosis of uterine fibroids. There 
are few diseases in which the young physician will be led into greater 
error or be made to regret more decidedly an over-confident prediction. 
Fibroid tumors, unless of great size, rarely end fatally, however gloomy 
the prospect may appear when they are first discovered. And yet 
death from them is not so infrequent as to warrant an entirely favorable 
prognosis. 

Frequency. — These statements are to a certain degree corroborated 
by an examination into their frequency. Were they as dangerous as is 
sometimes supposed, a large number of deaths would be annually pro- 
duced by them, for, to use the words of McClintock, "without question 
the most frequent organic disease of the uterus, if we except inflamma- 
tion and its effects, is fibrous tumor." Bayle estimated that of all 
women dying beyond thirty-five years of age, 20 per cent, were thus 
affected. Even supposing that this assumption was an exaggerated one, 
an idea of the frequency of the affection may be gathered from the 
fact of his venturing upon it, and surprise at it will be modified when 
the following extract is read from Klob. 1 In speaking of their fre- 
quency he says : " At the climacteric period it is such that undoubtedly 
40 per cent, of the uteri of females who die after the fiftieth year con- 
tain fibroid tumors." 

Let the diagnostician who has discovered a uterine fibroid, and feels 
prompted to give a grave prognosis concerning it, bear these facts in 
mind, and he may be prevented from injuring his patient's comfort and 
his own reputation by so doing. 

Course, Duration, and Termination. .—As already stated, these 

1 Op. cit, p. 177. 



PALLIATIVE TREATMENT. 523 

growths may attain the enormous weight of fifty pounds. Fortunately, 
they very rarely reach such dimensions, but even when they do not 
they sometimes exhaust the patient by metrorrhagia, leucorrhcea, hyd- 
rorrhoea, and a low grade of constitutional irritation, often attended by 
hectic fever. But this termination, like the preceding, is exceptional. 
Having attained a moderate size, they generally remain stationary or 
increase slowly until the menopause, creating considerable inconvenience 
and depreciating the patient's strength by hemorrhage. Then, under- 
going a certain degree of atrophy with the cessation of uterine and 
ovarian functions, they cease to be to any degree a source of annoyance 
or at least of danger. Even during the age of uterine activity nature 
may, unaided, effect a cure by the following means : 

Absorption or atrophy ; 

Direct expulsion by rupture of attachment ; 

Sloughing from deprivation of nutrition, or inflammation; 

Calcareous degeneration ; 

Gangrene. 
The tumor is sometimes deprived of nutrition by inflammatory action 
occurring in the vascular structure of the uterine attachment, which 
has already been described, collections of pus being sometimes discov- 
ered in it. 

Throughout their existence these tumors sympathize in the uterine 
changes which attend upon these three conditions : menstruation, utero- 
gestation, and the menopause. With the occurrence of menstruation 
they, like the tissue of the uterus, become congested, enlarged, and sen- 
sitive. During pregnancy their component muscular fibres grow, and 
probably undergo retrograde metamorphosis after delivery. As senile 
atrophy succeeds the menopause their nutrition is impaired, and fatty 
and calcareous degeneration sometimes occurs. 

Sometimes fluid collections take place within these masses, some 
morbid process destroying their tissue as if by liquefaction. The fluid 
thus collecting may be purulent, watery, or sanguineous. In some cases 
a colloid degeneration is said by pathologists to occur in or near the 
centre of the mass, which softens down and liquefies the fibroid tissue. 
In others an apoplexy takes place which creates the initial cavity, and 
this is subsequently found filled with the debris of the clot and with 
turbid serum. 

Palliative Treatment. — In the vast majority of cases of interstitial 
and subserous fibroids the efforts of the practitioner should be limited 
to palliation of the evils resulting from these growths. These evils 
will generally be due to either one or all of the three following condi- 
tions which result from them : displacement of the uterus, pressure on 
surrounding organs and parts, and menorrhagia or metrorrhagia. The 
first will often be greatly relieved by restitution of the displaced organ. 
and its retention at, or even above, the superior strait. This may be 
accomplished by the ordinary means of replacement and the use of the 
bulb pessary (Fig. 221) in difficult cases, or of one of the varieties of 
intravaginal anteversion or retroversion pessaries in less obstinate ones. 
By a properly-adjusted pessary, aided by complete removal of weight 
and constriction from the abdomen and the use of an efficient abdominal 



524 FIBROID TUMORS OF THE UTERUS. 

pad, the second set of evils may be ameliorated. Relief of hemorrhage 
generally proves difficult, and not rarely impossible. The presence of the 
fibroid in utero keeps up congestion of the endometrium, and this results 
in leucorrhoea, hydrorrhea, and menorrhagia. Fortunately, good can 
generally be, to a limited extent at least, effected by rest in the recum- 
bent posture during the menstrual periods ; the use of hemostatic agents, 
as elixir of vitriol, ergot, viscum album, Hydrastis canadensis, cannabis 
Indica, gallic acid, etc., and the use of the tampon after the loss of 
blood has reached an amount equal to that lost during normal men- 
struation. The practice of applying a tampon of carbolized cotton 
impregnated with solution of alum after a menorrhagic flow has, under 
these circumstances, lasted for four or five days, we often resort to, and 
never with any but good results. Without some such controlling influ- 
ence the patient will commonly become greatly exsanguinated. While 
these means are being adopted the bowels should be kept regular and 
the functions of the skin and liver carefully supervised. 

In some cases the engorged condition of the mucous membrane lin- 
ing the uterus causes it to become covered by little fungoid growths, 
which keep up and greatly increase the amount of hemorrhage. Under 
these circumstances the application of the wire curette is of great serv- 
ice. Even if there should be an error in diagnosis, this treatment will 
accomplish good by severing the distended vessels of the mucous mem- 
brane and relieving congestion. 

Should it be found that by this means even hemorrhage is not suf- 
ficiently controlled, resort should be promptly had to palliative resources 
of a more decidedly surgical character. These may prove efficient as 
hemostatics, while at the same time they prepare the way for curative 
means if they should be in time deemed necessary. 

It has been found that hemorrhage due to uterine fibroids is often 
greatly diminished by section of the uterine neck, a practice which was 
first inaugurated by Amussat, and imitated by JNelaton, Brown, and 
McClintock. In some not very explicable manner cutting through the 
cervical canal by deep incisions on its sides exerts a good influence in 
controlling this form of hemorrhage. A still more powerful effect will 
follow incision directly through the investing coat of the tumor itself, 
so as to cut its capsule, its superficial layer of fibres, and its superficial 
blood-vessels, and thus diminish its vascular supply. When, however, 
the tumor becomes so accessible as to render this possible, complete 
removal becomes so likewise, and should be preferred. 

Curative Medicinal Mea?is. — Whether absorption of these neoplasms 
can be excited by any of those medicines styled absorbents is not cer- 
tainly ascertained. Tumors have in some instances been known to 
disappear while such drugs have been employed, and perhaps they did 
so in consequence of their use. But no such effect can be looked for 
with any confidence. Indeed, with our present experience such a result 
must be regarded as decidedly exceptional. Scanzoni, after advising 
those medicines which are most popular as stimulants of absorption, 
savs : " We do not remember a single case in which, with the means 
indicated or with others, we have obtained the complete cure of a fibrous 
body." If such drugs be tried for this purpose, they should be con- 



CURATIVE MEDICINAL MEANS. 525 

tinued for many months, and even a year or two, before the trial can 
be considered fairly made, for their action is never immediate. Those 
in greatest esteem are iodine, the iodide and bromide of potassium; 
that class of drugs supposed to possess the power of inducing fatty 
degeneration, as arsenic, phosphorus, and lead — " steatogenic " drugs, as 
they have been styled ; preparations of lime ; and the waters of cer- 
tain mineral springs, as Kreuznach, Kissingen, Krankenheil, etc. 
Some of these waters may be employed externally in the form of baths 
as well as internally. 

The late Prof. Hildebrandt of Konigsberg some twenty years ago 
published very elaborate reports of a number of cases of fibroids of 
different varieties which he had benefited, and in part cured, by the 
injection of a solution of ergot under the skin. In some of his cases 
the result was simply marvellous, even large tumors entirely disappear- 
ing after a comparatively limited number of injections, and where the 
tumor did not disappear its diminution was marked, the hemorrhages 
ceased, and the pains were relieved. His statements attracted wide- 
spread attention, and his method was tested by many practitioners all 
over the world. To a certain extent it was found that the assertions of 
its inventor — namely, that the growth of uterine fibroids was arrested 
by the contraction of the enclosing muscular fibres of the organ and 
the interference with the blood-supply thereby produced — were true, and 
for a time many experiments were made with this procedure ; but there 
were certain disadvantages attending it which generally led to its aban- 
donment, so that at the present day very little is heard of it. The 
chief of these objections were the pain and suppuration very commonly 
produced by the hypodermatic injections ; further, the danger of causing 
gangrene and sloughing of the tumor in consequence of the diminished 
blood-supply produced by the uterine contractions ; and finally, the 
increased employment and success of the removal of these tumors by 
laparotomy or their control by the local application of the galvanic 
current. Although, as we have stated, the systematic employment of 
this method for the cure of uterine fibroids has practically been discon- 
tinued, we would still advise the employment of deep hypodermatic 
injections of one-half to one syringeful of Squibb's fluid extract of 
ergot into the abdominal wall near the umbilicus whenever dangerous 
uterine hemorrhage demands immediate interference. This might be 
the case either with uterine fibroids, or perhaps more frequently in 
post-partum hemorrhage. 

To Drs. Cutter of Boston and Kimball of Lowell probably belongs 
the credit of having first carried out systematically the treatment of 
uterine fibroids by electro-puncture. In 1880, Dr. Cutter reported 50 
cases treated in this manner, 4 of which were cured, 82 improved, 4 
ended fatally, and the rest were not benefited. Their method consisted 
in plunging large, gutter-shaped electrodes through the abdominal walls 
into the tumor on each side of the median line, and connecting them 
with the two poles of the battery. It is apparent that, in spite of the 
comparatively slight mortality following this heroic treatment in the 
hands of its authors, the method on its face was too dangerous to excite 
approval or imitation. So far as we know, it has now fallen entirely 



526 FIBROID TUMORS OF THE UTERUS. 

into disrepute. In place of it, however, has come the abdomino-intra- 
uterine application of the galvanic current, known as the Apostoli 
method, which has attracted more attention during the last five years 
than perhaps any other single subject in gynecology. For our esti- 
mate of it, and the details of its employment so far as the limit of this 
work goes, we refer the reader to the chapter on the Use of Electricity 
in Gynecology. We will merely say here that we consider its utility 
unquestionable in a certain number of cases ; that Ave believe that in 
some instances the tumor may be entirely dispersed, in others dimin- 
ished in size, and in others, again, the symptoms totally relieved ; but 
that complete and permanent cure can be expected, so far as our pres- 
ent experience goes, only in a comparatively small number of cases. 
Galvano-puncture per vaglnam in suitable cases, with the other pole on 
the abdomen, is in our opinion more effectual, while, however, more 
risk\r. 

Before taking up the consideration of the surgical resources appli- 
cable to uterine fibroids, we would sum up the general management of 
their varieties in the following manner : 

1st. With the means at present at our command all the varieties of 
fibroids, the subserous, the submucous, and the interstitial, are amena- 
ble to extirpation ; but the danger of removing the first by laparotomy 
is so great that this should not be resorted to unless life be threatened 
by the non-removal of the tumor. 

2d. If an interstitial fibroid be readily accessible by cutting through 
its investing tissues, it should be removed. 

3d. Submucous fibroids divide themselves into two classes, thus : if 
the os internum be obliterated and the tumor present at or within the 
os externum, the case is most favorable for removal ; if the os internum 
be unyielding and the cervical canal undilated, danger will always attend 
dilatation preliminary to removal of the growth. 

4th. In cases unfavorable for removal it is best to resort to good diet, 
tonics, ergot, and means calculated to palliate symptoms, and await an 
alteration in existing circumstances, which may prove more favorable to 
a resort to radical treatment. 

Curative Surgical Procedures. — The gynecologist of to-day in recog- 
nizing the important advances in his department, signalized by the dis- 
covery of ovariotomy, the cure of vesico-vaginal fistula, and reparative 
operations upon the perineum, the uterus, and the vaginal walls, often 
forgets how much has been done in reference to the extirpation of ute- 
rine fibroids of all three varieties. Prior to the present century, and 
even during the first half of it, the operation of laparotomy for subperi- 
toneal tumors of this class was unknown, interstitial tumors were unin- 
terfered with, and he who studies the methods of those who attacked 
submucous growths by the constricting ligature will at once appreciate 
how hazardous, difficult, and uncertain were the means at the disposal 
of the surgeon of the olden time for dealing with them. 

The keynote to the modern advance in this subject was struck by 
Heath and Charles Clay in 1846 ; by Burnham of Lowell, who per- 
formed the first successful operation by laparotomy in 1853 ; and by 
Dr. W. L. Atlee of Philadelphia, when in the year 1853 he presented 



CURATIVE SURGICAL PROCEDURES. 527 

to the American Medical Association an essay entitled "The Surgical 
Treatment of Certain Fibrous Tumors of the Uterus heretofore consid- 
ered beyond the Resources of Art." This essay received the prize of 
the association, and to-day stands as the pioneer article in the surgical 
literature of these grave and otherwise irremediable cases. 

Both in this country and in Europe the lead of this bold surgeon 
has been followed, and the methods which he advocated a quarter of a 
century ago, and which slowly battled with a pretty decided opposition, 
have come to be recognized as legitimate surgical resources. 

The views of Atlee, as published in 1853, may be epitomized in these 
three propositions : 

First — If a non-pediculated tumor cannot, from the nature of its 
attachment and envelopes, be expelled or drawn by mechanical means 
through a dilated os uteri, it is advisable to make by the knife a means 
of escape for it into the uterine cavity through its capsule or enveloping 
tissues. 

Second — If the tumor thus oifered an outlet cannot be removed, it 
should be forced into and out of the uterine cavity by cutting the cervix 
and persistently using ergot. 

Third — The tumor once coming within reach, it should as soon as 
practicable be enucleated or detached and removed by the surgeon. 

Of course, each one of these methods should be carefully considered 
before subjecting the patient to the dangers which undoubtedly attend 
surgical interference of so serious a nature. Septicaemia, peritonitis, 
hemorrhage, and exhaustion may follow r the successful, and still more 
the unsuccessful, attempt to remove these growths. It should be borne 
in mind that, as a rule, an operation of this kind once begun ought to 
be concluded, in order to avoid as much as possible the above dangers, 
and above all is stress to be laid on the fact that before attempting to 
remove a deep-seated, non-pediculated uterine tumor through the cer- 
vical canal the external and internal orifices of the uterus should be at 
least as widely dilated as the transverse diameter of the tumor. We 
know of no more difficult or dangerous operation than to attempt to 
extract a sessile fibrous tumor which is larger than the cervical canal 
through which it is to be drawn. Dilatation of the cervical canal, 
therefore, by successive sets of tupelo tents, discission of the intravag- 
inal portion of the cervix, and even of the circular fibres of the inter- 
nal os, should therefore accomplish what, fortunately in many cases, the 
expulsive efforts of the uterus have already performed. Once let the 
intra-uterine tumor present through the dilated cervical canal, like the 
foetal head on the point of exit from the uterus, and the enucleation 
and removal of the tumor after thorough incision of its capsule is an 
easy matter and unattended with much danger. 

The plans now usually adopted for the extirpation of submucous and 
interstitial fibroids may thus be summarized : 
Excision ; 
Avulsion ; 
Enucleation. 

The two elements which govern success in the removal of these 
growths by the surgical processes which now come to be considered are 
34 



528 



FIBROID TUMORS OF THE UTERUS. 



these : first, the degree of projection of the tumor into the uterine cav- 
ity ; second, the degree of dilatation of the cervical canal. We do not 
say that they decide the propriety of operation. Removal may be 
practised where the tumor is to a great extent interstitial, only causing 
slight protrusion inward of the mucous membrane, and where the cer- 
vical canal is completely contracted. But in such cases it is more dif- 
ficult of accomplishment, and much more dangerous to the life of the 
patient. An interstitial fibroid excites uterine contractions, which in 
time usually extrude it, making it either subserous or submucous. In 
both cases it carries with it a covering of uterine tissue, which when it 
enters the uterine cavity is one of the influences which prevent its 
expulsion into the vagina ; the closure of the cervix being another. 
In some cases Nature unaided overcomes these obstacles. When they 
are too powerful for her, Art comes to her aid and removes them. 

If the cervical canal be sufficiently dilated to allow of immediate 
access to the tumor, much danger, delay, and trouble is avoided by 
that condition. If it be deemed best to force open the way to the neo- 
plasm, the cervical canal may be distended by cutting through it up to 
the vaginal junction, and giving ergot to expand it, by dilating it 
gradually by tents, and by forcibly dilating it by water-bags or by 
graduated dilators. Hydrostatic dilatation is applicable only when the 
part is dilatable and offers little resistance. 

The ordinary water-bags known as Barnes's dilators are not power- 
ful enough for the expansion of the cervix of the non-puerperal uterus, 
and besides this they dilate irregularly. Molesworth's dilators, shown 
in Fig. 252, are by far more efficient in these cases. The objection to 




Molesworth's Cervical Dilators. 



this instrument, however, is that if not frequently used the rubber 
tubes become so brittle that when distended Avith water they are very 
liable to rupture. Hence we have reluctantly abandoned this instru- 
ment, except when we happened to have perfectly fresh tubes. 

The method which we now chiefly employ, and have found safest 
and most certain for the dilatation of the canal preparatory to the 
removal of a submucous intra-uterine fibroid, is to divide the cervix 
from the external os to the insertion of the vagina bilaterally with scis- 
sors ; then to incise the internal os with the blunt-pointed bistoury 
until the resistance of the circular fibres is overcome ; and finally secure 
the necessary additional dilatation by means of large tupelo tents, 



EXCISION -A VULSION. 529 

repeated daily so long as necessary. During all this time ergot is 
given in doses of gtt. xx of the fluid extract or one grain of the solid 
extract every three hours, in order to force the tumor into the cervical 
canal. The faradic current might also be employed daily for the same 
purpose. These combined efforts may require several weeks or even 
longer, but should almost inevitably, in time, bring a submucous fibroid, 
even though it be attached to the fundus, within reach of the scissors, 
vulsella, and fingers for removal. 

Excision. — Formerly a small submucous fibroid projecting into the 
uterine cavity was removed by the severance of its attachments with 
the knife, scissors, or some other cutting instrument. For this purpose 
so-called polypotomes were devised, which acted by grasping the attach- 
ment of the tumor and dividing it by means of a blade pushed forward 
in the handle of the instrument, or the attachment of the tumor was 
encircled by a loop of wire or a steel chain carried in by an instrument 
called the dcraseur or constricteur, the tightening of which loop through 
a mechanism in the shaft of the instrument gradually severed the ped- 
icle. These complicated instruments have now been discarded for sev- 
eral reasons, among which may be mentioned the difficulty of applying 
them to the exact point which it was desired to encircle ; the danger of 
cutting off or drawing into the loop more tissue than was intended, 
Avhereby the peritoneal cavity might accidentally be opened ; and finally 
the ease with which these tumors could be removed with perfect safety 
by the' methods already described or still to be considered. 

One of the reasons why the ecraseur and constricteur were employed 
for the removal of pediculated intra-uterine tumors or for polypi was 
the fear of hemorrhage from the severed stump, which was supposed to 
be arrested by the slow, dull division by the wire or chain. Experi- 
ence has now shown that such bleeding need never be feared, since the 
retraction of the attachment of the tumor and the contraction of the 
body of the uterus almost invariably control the hemorrhage. Besides, the 
uterine cavity may be tamponed with iodoform gauze if any additional 
precaution seems advisable. A number of instances are on record in which 
the separation of the tumor from its more or less broad attachment to the 
uterine wall by the chain or wire loop has resulted in a perforation of the 
organ and in the opening of the peritoneal cavity ; and these accidents 
have occurred in the hands of the most experienced operators. 

Avulsion. — In certain cases the broad attachment of the tumor to 
the upper portion of the uterine cavity, the length of the uterine canal, 
and the difficulty of bringing the tumor within reach of the finger or 
instruments by which it may be detached entire, oblige us to remove it 
piecemeal by a method different from that employed in the preceding 
section. This remark applies as well to comparatively small growths. 
such as is shown in Fig. 249, as well as to larger (Fig. 250) tumors 
which resisted the attempts at removal en ))iasse. After dilatation of 
the cervical canal and incision of the capsule or mucous membrane cov- 
ering the tumor, the instrument shown in Fig. 251 is passed into the 
uterine cavity, either joined or blade by blade like the obstetric forceps, 
a portion of the mass is seized, and, the forceps being securely locked, 
is removed by a steady rotary motion which tears the grasped portion 



530 FIBROID TUMORS OF THE UTERUS. 

from its attachments. This manoeuvre is repeated again and again, 
under the careful guidance of the finger, until the whole tumor has 
been removed. It may not be possible to accomplish this in one sit- 
ting, but with ordinary precaution as to avoidance of undue force and 

Fig. 253. 



Goodell's Avulsion Forceps for Sessile Fibroids and Fundal Polypi. 

employment of antisepsis, no bad results need be feared. The more of 
the tumor that is removed, the smaller does the uterine cavity become 
and the easier can the tumor be reached. We have thus removed, and 
seen removed by other operators, tumors varying in size from a fig to a 
foetal head. After each sitting the uterine cavity is irrigated with a 
1 : 10,000 solution of bichloride, and packed with iodoform gauze to 
guard against hemorrhage, septic infection, and possible inconvenient 
closure of the canal. This method of removing fibroids has been called 
by the French " morcellement" meaning removal in pieces. 

Enucleation and Traction. — As long ago as 1840, Amussat, at Vel- 
peau's suggestion, performed enucleation of an interstitial fibroid. 
Anatomical investigations had shown that the attachments of many of 
these tumors to the surrounding uterine tissue were very loose, and 
that, after once dividing the layer of mucous membrane and muscular 
fibres covering the presenting portion of the growth, the tumor could 
very commonly be shelled out from its bed with the finger or some blunt 
instrument, without in any way injuring the normal tissues or interfering 
with the rapid recovery of the patient. Since then this operation of 
enucleation has been practised by very many gynecologists whose names 
are too numerous to mention. The one great and almost indispensable 
condition for the easy and safe performance of this operation is the 
thorough dilatation of the cervical canal and the easy accessibility of 
the tumor to both fingers and instruments, so as to enable the operator 
to Avork readily and safely. The capsule is then incised to the extent 
of several inches, the finger inserted and swept about until a sufficient 
surface of the tumor is exposed to allow of the insertion of a pair of 
vulsellum forceps. With these steady traction is made, the finger con- 
tinues the separation of the tumor, and as each successive portion of 
the mass becomes accessible the vulsella are inserted into it, the trac- 
tion being steadily kept up. In this manner very soon the tumor is 
rolled out of its bed, either entirely peeled loose by means of the 
finger, or by means of the blunt curved scissors, or by an instrument 
known as Thomas's spoon-saw. In this manner we have succeeded in 
removing tumors weighing up to three pounds, with invariable recovery 
of the patient. The large cavity remaining after the removal of such 
growths should be packed with iodoform gauze, loose mutilated portions 



ENUCLEA TION. 531 

of the capsule being removed with scissors. There need be no fear of 
hemorrhage, since, as already stated, the uterus always contracts sharply 
after the removal of the tumor. We consider this method of enuclea- 
tion with traction to be by far superior to any other means of removing 

Fig. 254. 




Thomas's Spoon-saw. 

submucous and interstitial fibroids from the uterine cavity; but we 
must again repeat that to the successful and safe employment of this 
operation the thorough dilatation of the cervical canal and the entire 
accessibility of the tumor are indispensable conditions. Furthermore, 
we would except from its performance very large and deeply sessile 
tumors situated near the fundus uteri, preferring in such cases to post- 
pone operative interference until we have succeeded in forcing the 
tumor down to the internal os or still deeper. In some cases, notably 
those where an interstitial tumor is situated at or near the fundus, not 
impinging on the uterine cavity more than it does toward the peritoneal 
envelope, and where the cervical canal is long and rigid and undilated, 
we would infinitely prefer to perform laparotomy, incise the peritoneal 
envelope, enucleate the tumor, and close the incision by sutures, than 
to attempt its removal by the natural passages. 

If at all possible, it is advisable to complete enucleation by traction 
in one sitting • still, we have several times been obliged, through 
exhaustion of the patient or insufficient dilatation of the cervical canal, 
to perform the operation in several sittings, each time detaching a little 
more, with a final successful result; but of course danger of traumatic 
reaction and of septic infection from these repeated interferences should 
be borne in mind. We will not, however, deny the occasional utility 
of freely incising the capsule of the tumor and endeavoring to force it 
through the incision by the steady administration of ergot ; still, when- 
ever it is possible so to incise the capsule that the tumor can be forced 
through by the uterine contractions, it ought usually to be possible to 
enucleate and remove it at the same sitting. The serrated spoon-saw, 
which in our last edition we recommended so highly for the detachment 
of submucous and interstitial fibroids, is now not used by us with any- 
thing like the frequency which it was at that time, for the reason that 
we found it a rather dangerous instrument if employed without the 
guidance of the fingers, as it must be in tumors attached near the 
fundus uteri, and further because by the means already described we 
were able to remove the growths without a special difficulty. Besides, 
the instrument has in the hands of a number of gentlemen accom- 
plished damage by perforating the uterine wall. 



532 FIBROID TUMORS OF THE UTERUS. 

A plan recommended by Baker Brown and some others many years 
ago, of mutilating these growths by incisions and punctures and pro- 
ducing their sloughing with the object of gradually effecting their 
removal, need only be mentioned in order to be condemned. Nature 
herself occasionally effects these changes, usually with more or less risk 
to the patient, although many cases are on record where chiefly sub- 
mucous and interstitial fibroids have become gangrenous, and have been 
gradually discharged by uterine contractions. Still, the danger of sep- 
tic infection under these conditions is too obvious to require more than 
casual mention. In this connection we may say that these tumors occa- 
sionally calcify, undergo fatty degeneration, become liquefied, swell, 
and shrink or are spontaneously absorbed. 

Laparotomy, or Abdominal Hysterectomy. — Following in the wake 
of the ovariotomists, at first unintentionally and eventually by design, 
the removal of large fibroid tumors of the uterus by abdominal section 
became an accomplished fact. The first operators mistook the tumors 
for ovarian cysts, and completed the operation rather than admit their 
error ; some, recognizing their mistake, closed the abdominal cavity 
without removing the tumor. Such were the cases of Lizars in 1825, 
Dieffenbach in 1826, and more recently Atlee in 1849, Baker Brown, 
Cutter, and others. Fourteen of these cases are published, five of which 
terminated fatally. Other surgeons completed the operation, and the 
credit of the first successful removal of a large fibroid tumor of the uterus, 
together with that organ and the ovaries, is due to an American, Burn- 
ham of Lowell, Mass., in the year 1853. Kimball of the same city, 
already mentioned as a pioneer in the electrical treatment of these 
tumors, closely followed Burnham with a series of cases of removal by 
laparotomy. Following in their lead, but independently, H. R. 
Storer of Boston in the year 1866 unconsciously removed the whole 
uterus with both ovaries by abdominal section, with a fatal result, the 
exact character of the tumor not being discovered until after removal. 
Next came Koeberle of Strasburg, who up the year 1869 had per- 
formed 9 hysterectomies with 4 recoveries. His method was to enclose 
the pedicle of the tumors — that is, the smallest portion of the mass 
next to the cervix — by a steel wire carried in an instrument called a 
constrictor, which permitted the gradual tightening of the wire until it 
firmly encircled the point to be constricted. Hemorrhage was thus pre- 
vented, and the pedicle of the tumor held in place after the ablation of 
the mass above the constricting wire. The abdominal wound was closed, 
the pedicle being held in the lower angle of the wound by the con- 
strictor. 

Pean of Paris was the next to take up this operation, and in a work 
published by himself and his associate, Urdy, in 1875 he astonished the 
professional world by his reports of numerous successful cases of fibroid 
tumors removed by laparotomy. Pean's method consisted chiefly in the 
diminution of the tumor by excising portions of it after the abdomen 
was opened, guarding against hemorrhage by compression with large 
forceps or by the encircling of the pedicle with a metallic ligature 
twisted by the instrument known as the serre-nceud (or knot-tier) of 
Cintrat ; to prevent the slipping of the pedicle two long steel pins were 



LAPAROTOMY. 533 

passed at right angles through the pedicle above the wire. In more 
recent years (1880) Hegar perfected this operation and introduced the 
method which is now most generally employed. 

In place of the wire loop, transfixion and ligation of the pedicle in 
sections with strong silk has been practised ; clamps also, which were 
tightened by a screw, have frequently been employed ; but at the pres- 
ent day the elastic ligature, composed of solid rubber or of rubber 
tubing (the latter being the least likely to break), has superseded the 
other forms of compression of the pedicle. The first to use the elastic 
ligature for this purpose was Kleeberg of Odessa, on the 8th July, 1876. l 
Many operators, after ligating the stump with strong silk applied in sec- 
tions, sewed it into the abdominal wound, covering the surface of the 
pedicle with the abdominal parietes. We saw Billroth perform such an 
operation in 1886 ; but the other methods mentioned contained the one 
salient feature that the pedicle is treated extra-peritoneally, the cut sur- 
face of the stump being exposed in the abdominal incision wdiich is 
closed all around it. In contradistinction to this extra-peritoneal treat- 
ment of the pedicle comes the method devised by the late Prof. Schroeder 
of Berlin, which consists in temporarily constricting the pedicle of the 
tumor by a ligature, either elastic or otherwise, removing the tumor, 
and then bringing the surfaces of the pedicle in apposition by means 
of deep and superficial silk sutures. When all danger of hemorrhage 
from the stump has thus been guarded against, the latter is dropped into 
the abdominal cavity precisely as in ovariotomy. This is called the 
intra-peritoneal treatment of the pedicle. 

Indications for the Removal of Fibroid Tumors by Laparotomy. — 
While an ovarian tumor should, on the general principle that it will 
infallibly sooner or later endanger the life of the patient, ahvays be 
removed as soon as recognized, the same rule does not apply to uterine 
fibroids. So long as they do not affect the life or health of their pos- 
sessor, either by producing dangerous hemorrhage or by interfering 
with the comfort or nutrition of the woman through rapid growth and 
pressure upon vital organs, they need not necessarily be interfered 
with, since in themselves they are not likely to prove fatal. But when 
a large subperitoneal or interstitial fibroid tumor shows, by its rapid 
growth in a comparatively short time, that it will sooner or later inter- 
fere most decidedly w r ith the well-being of the patient, or if its size 
already so interferes, or if by its situation it happens to cause much 
pain or to obstruct the circulation in some of the abdominal viscera or 
in the lower extremities, the indication may arise for the only abso- 
lutely sure treatment of removing the growth. No hard and fast rule, 
such as applies to ovarian tumors, can therefore be laid down for the 
operative treatment of fibroids. Each case should be considered and 
treated on its individual merits, and- the fact should not be forgotten 
that fibroid tumors seldom kill, and that the operation for their removal 
is vastly more dangerous than that of ovariotomy. We would there- 
fore advise that the indication for abdominal hysterectomy for fibroids 
be very carefully and closely limited; and we can truly say that only a 
very small proportion of such eases which have come under our per- 

1 St. Petersburg med. Wochenschrift, Nos. 6 and 24, September, 1ST 7. 



534 



FIBROID TUMORS OF THE UTERUS. 



sonal observation have been thought by us to justify the operation of 
laparotomy. 

Fig. 255. 




Intra-parietal Treatment of Stump (Woelfier-Hacker). 

a. b, deep and superficial sutures of incision; c, skin ; m, muscle; e, e, sutures attaching peritoneum of 

stump to abdominal wall ; PP, parietal peritoneum; Pv, visceral peritoneum ; Ut, uterus. 

Operation. — The preparatory details of the operation will be more 
fully considered under the head of Ovariotomy, with which up to a cer- 

Fig. 256. 




Pean's Extra-peritoneal Fixation of Pedicle. 
(The elastic ligature is here substituted for the wire loop and serre-nceud.) 



LAPAROTOMY. 



535 



tain point they are identical. After opening the abdominal cavity in 
the usual manner, the tumor may be extracted by means of vulsella 
forceps or by a much better instrument first recommended by Tait — 
namely, an ordinary corkscrew, or perhaps two or more, which are 
inserted into the mass at several points, and by means of which the 
tumor is lifted out of the abdominal cavity. If the ovaries have grown 
up with the tumor, they are of course attached to its upper portion and 

Fig. 257. 




are extracted with it. If, however-, the tumor has grown from the 
fundus and has left the lower portion of the uterus more or less unde- 
veloped, the ovaries may be found well down in the pelvis, and in order 
to free the smallest portion of the tumor — that is, that situated imme- 
diately above the vaginal vault — a separate ligature of each broad lig- 
ament with the ovarian artery is required, the ligature being applied 
double and the broad ligament divided between. In this way the 



536 FIBROID TUMORS OF THE UTERUS. 

narrowest portion of the pedicle is set free. Care is of course taken 
by previous sounding to avoid injuring the bladder. The narrowest 
portion of the pedicle having been exposed, it is encircled .by one 
of the compressing agents already referred to (clamp, wire, ligature, 
ligature in sections, elastic ligature, the last three protected by trans- 
verse pins), and the tumor is cut off above. If the ovaries have not 
been included in the mass removed, their attachments should be ligated 
separately and the organs removed. The pedicle is then treated by one 
of the methods now to be described in detail, and the abdominal cavity 
closed. The after-treatment of the patient is carried on after the prin- 
ciples to be described under Ovariotomy. 

a. Extraperitoneal Treatment of the Pedicle. — 1. Peans Method. 
— Transfixion and constriction of pedicle by wire loop, twisted and 
retained in place by Cintrat's serre-nceud. Two steel pins at right 
angles prevent the slipping of the loop. The stump is fastened in the 
lower angle of the wound, which is tightly closed about it. The sur- 
face of the stump is charred by means of the actual cautery. 

2. Hegars Method. — Elastic ligature, ablation of tumor, stitching 
of pedicle into lower angle of wound by sutures attaching the parietal 
peritoneum to the peritoneum of the pedicle below the ligature ; careful 
closure of the abdominal wound, excision of the stump as deeply as 
possible, also of the cervical mucous membrane; cauterization with 
saturated solution of chloride of zinc. Some operators (as, for instance, 
Munde) employ the steel pins to prevent the slipping of the elastic 
ligature. 

In these extra-peritoneal methods the portion of the stump above 
the ligature must necessarily slough off. This process can be aided by 
cutting away dead tissues as the necessity may appear. Careful disin- 
fection and thorough cleanliness will usually prevent septic infection. 
The objection to this method is the length of time, usually from two to 
three weeks, required before the sloughing of the stump permits the 
removal of the ligature, and the subsequent tedious delay in the heal- 
ing of the wound. Another objection is also the not uncommon per- 
sistence of a vagino-abdominal fistula, wdiich requires a separate ope- 
ration for its closure, both from the vagina and the abdominal wall. 

In order to do away with this tedious if not dangerous sloughing 
process of the Constricted pedicle, some operators (Chrobak, Barden- 
heuer, Martin) have practised the excision of the cervical stump after 
removing the bulk of the tumor, having of course previously ligated 
the ovarian and uterine arteries on either side. The wound thus made 
in the vaginal vault is closed by sutures introduced through the abdom- 
inal wound, or it may be left open and drained by iodoform gauze. 
This complete extirpation of the uterus — body and cervix and all — at 
one sitting is of course the ideal method, but it is technically more dif- 
ficult, and therefore more serious to the patient, than the extra-peri- 
toneal treatment of the stump. However, Chrobak (latest report 1 ) 
shows 17 such operations done (after a slightly modified method) during 
the last nine months, with no death. 

b. Intraperitoneal Treatment of the Pedicle. — Schroeder w r as the 

1 Centralbl. fur Gyn., Aug. 29, 1891. 



LAPAROTOMY. 



537 



chief advocate of this method. After ligating the broad ligaments 
with all the vessels on either side with a double thread and dividing 
between them, the tumor is lifted up, a coil of elastic tubing applied 
tightly about the cervix, and the tumor removed. A transverse wedge 
is now cut out of the stump down to the elastic ligature, any project- 
ing vessels are seized separately and ligated with catgut, the cervical 
mucous membrane is exsected, and the edges of the incision are then 
brought together at different levels ; the cervical canal being first 
sutured, then the deeper portions of the wound, and finally the peri- 

Fig. 258. 




Intra-peritoneal Treatment of Stump (Schroeder, Kelly, etc.) 
S, deep silk suture passed first under the whole denuded surface; C, continuous catgut sutures composed 
of superimposed turns covering the whole of the wound, of which the lower part is marked by a broad 
black line, a a, formed by the cauterized uterine cavity ; P, peritoneal coat. 

toneum brought together over the surface of the stump by interrupted 
silk sutures. The elastic ligature is then removed, and after thorough 
cleansing of all the parts and the assurance that no hemorrhage is 
taking place, the stump is returned to the abdominal cavity and the 
wound closed. 

There are numerous modifications of the principle of both the extra- 
and intra-peritoneal methods. Saenger, Zweifel, Tauffer, Woelfler. and 
Howard Kelly may be chiefly mentioned as having introduced more or 
less original and valuable improvements of these two modes of ope- 
ration. In fact, every operator of repute may be said to have some 
special method of his own which he prefers to any other. Our space 
does not permit us to treat of all these modifications and methods in 
detail. 

The question as to whether the extra-peritoneal or the intra-peri- 
toneal treatment of the pedicle is the safer and preferable is not as yet 
entirely settled. There can be no doubt that the intra-peritoneal treat- 
ment of the pedicle devised by Schroeder is really the ideal one, since 



538 



FIBROID TUMORS OF THE UTERUS. 



by it the pedicle is dropped as in ovariotomy, and, if all goes well, is 
henceforth entirely lost to view, and the abdominal cavity is at once 
closed and union by first intention is allowed to take place. But, 
unfortunately, the nature of the tissues involved in this operation dif- 
fers from that met with in ovariotomy. The thick, unyielding uterine 
neck is liable to shrink, and thus allow the ligatures to relax and hem- 
orrhage to occur. Further, the dangers of septic infection and of peri- 
tonitis are greater after hysterectomy than after ovariotomy. The 
deaths which have occurred after the intra-peritoneal treatment of the 
stump in hysterectomy have been due to one of these three causes. By 
the extra-peritoneal method the offending pedicle is constantly kept in 
view and accessible to whatever treatment it may require. Hence 
hemorrhage and septic infection are practically impossible, and peri- 
tonitis is the only danger to be feared. So far, the majority of ope- 
rators have achieved the best results from the extra-peritoneal method. 
The following tables, taken from Pozzi's recent treatise on gyne- 
cology, give the comparative results of the two methods, according to 
Wehmer : l 



a. Intra-peritoneal Method. 

„fope u S;;, i *« hs - M °»* i ">'' 



Gusserow . . 


19 


6 


31.6% 


Kaltenbach . 


5 


3 


60.0% 


Martin . . . 


86 


15 


17.4% 


Olshausen . . 


29 


9 


31.0% 


Spencer Wells 


26 


10 


38.0% 


Schroeder . . 


135 


41 


30.0% 


Taufler . . . 


12 


4 


33.0% 



312 



88 



28.2% 



b. Extra-peritoneal Method. 

Number 
of Operations. J 

Bantock ... 22 

Hegar .... 22 

Kaltenbach . . 22 

Keith .... 38 

Pean 52 

Tauflfer .... 17 

Spencer Wells . 20 

Lawson Tait . 54 

Thornton ... 15 



Deaths. Mortality 


9 


9.0% 


6 


27.0% 


1 


4.5% 


2 


5.3% 


18 


34.0% 


2 


11.7% 


10 


50.0% 


20 


37.0% 


2 


13.0% 



262 



(13 



24.0% 



Since in the above tables there are some of the most avowed par- 
tisans of the extra-peritoneal method represented in both the intra- 
and extra-peritoneal lists, in order to arrive at statistics free from this 
objection the following table has been prepared by Pozzi of intra-peri- 
toneal operations performed solely by men who practise this method 
only: 

Number of 
Operations. 

A. Martin S(y 

Olshausen 29 

Schroeder 136 

Gusserow 23 

Schultze 12 

Werth 11 

Dohrn 9 

Leopold 19 

Runge 11 

Zweifel 10 

345 

The mortality drops in this list to 25.5 per cent., but, as Pozzi 
says, if we eliminate from the extra-peritoneal lists the cases of certain 
1 Zeitschriftf. Geb. u. Gyn., xiv. 134, 1887. 



eaths. 


Mortality. 


15 


17.4% 


9 


31.0% 


41 


31.1% 


6 


26.0% 


3 


25.0% 


3 


27.2% 





0.0% 


/ 


36.8% 


4 


36.3% 


1 


10.0% 



LAPAROTOMY. 539 

notorious partisans of the other method, we find the mortality also to 
drop to 21.6 per cent. ; therefore, still far less than the best percentage 
from the intra-peritoneal method. Fritsch l has had but 5 deaths out 
of 23 operations treated by the extra-peritoneal plan (modified accord- 
ing to Woelfler-Hacker, the pedicle being attached between the lips of 
the incision), against 11 deaths out of 27 from the intra-peritoneal 
method. Albert 2 had but 1 death out of 30 operations by the extra- 
peritoneal, and Tauffer 3 12 deaths out of 51 by the same method. C. 
Braun and Hegar report equally good results — the first, 38 operations 
with 6 deaths ; the second, 32 with 2 deaths. We ourselves, except 
in a number of instances of pediculated fibroids in which we simply 
pierced and ligated the pedicle and dropped it back precisely as in 
ovariotomy, confess ourselves decided adherents to the extra-peritoneal 
method, having seen no special inconvenience from its employment, and 
no danger except that of peritonitis, which pertains to a certain extent 
more or less to all abdominal sections. If the pedicle was so thick that 
it was difficult to ligate, or if the tumor extended down into the pelvic 
cavity, we have succeeded in reducing the size of the pedicle by excis- 
ing a portion of it, or in the latter case by enucleating the pelvic por- 
tion of the mass. The possible persistence of an abdomino-cervical 
fistula we have already referred to as one of the objections to this 
method. In former years we employed as a means of constricting the 
pedicle a stout piano wire adjusted and twisted by the Cintrat serre- 
noeud or the Maisonneuve constricteur, later on the clamp devised by 
Thomas ; but of recent years Ave have found the elastic ligature, pro- 
tected against slipping by pins, to be the most convenient and easy 
method of constricting the pedicle. After the gradual excision of the 
sloughing stump and the removal of the pins, which usually takes place 
about the twelfth to the sixteenth day, the elastic ligature comes away 
by itself or is divided and removed. To guard against septic infection 
we have cauterized the stump with a saturated solution of chloride of zinc ; 
if very vascular, have even seared it thoroughly with the Paquelin cautery 
and kept it carefully dusted with iodoform. In no instance have Ave seen 
seJDtic infection proceed from the stump treated in this manner. Such of 
our cases as we have lost have died from peritonitis or from unsuspected 
adhesion of intestines to the intra-peritoneal portion of the pedicle. 

Dangers of Hysterectomy. — Abdominal hysterectomy for fibroids of 
the uterus is more dangerous than ovariotomy, because the organs 
removed are more vascular, hemorrhage is more likely to occur at the 
time of the operation and subsequently, the operation itself is more 
difficult and prolonged in consequence of the impossibility of diminish- 
ing the tumor before it has been extracted from the abdominal cavity. 
the almost inevitable shock attending the exposure of so large a mass 
of highly vascular serous membrane, and finally the septic infection 
likely to result, in spite of most careful antiseptic precautions, from 
the possible decomposition of the stump. 

The dangers may therefore be formulated briefly as — first, primary 

1 Volkmann's Sammlung klin. Vortr., 1889. 

2 " Laparotomien wegen Uterusmyomen," Wien. med. Pi'esse, £S, 1889. 

3 Cmtralblattf. Gyn. 



540 



FIBROID TUMORS OF THE UTERUS. 



or secondary shock or collapse ; second, primary or secondary hemor- 
rhage ; third, peritonitis ; fourth, septicaemia. As a rule, it is a safe 
plan to consider the occurrence of shock in all abdominal operations 
to be due to loss of blood rather than to nerve influence, and to look for 
the source of the bleeding when shock suddenly appears. The statis- 
tics cited above show indisputably that our modern methods of surgery, 
combined with antisepsis, and especially in the hands of operators accus- 
tomed to the frequent performance of abdominal section, have rendered 
even this formidable operation comparatively safe, so that where in 
former days 50 to 75 per cent, perished under the hands of the sur- 
geon, at present the mortality has dropped to from 21 to 25 per cent. 

Myomectomy. — To A. Martin of Berlin is due the credit of having 
introduced and perfected the method of enucleating large subperito- 
neal interstitial fibroids through an abdominal incision. He splits the 
capsule freely, peels out the tumor, and sews the walls of the cavity 
together by deep interrupted sutures, often draining the cavity toward 
the vagina if such a precaution seems to him necessary. (See Fig. 259.) 

Fig. 259. 




Myomectomy (A. Martin). 



Other forms of uterine tumors which are removable in this manner 
are those that develop between the layers of the broad ligament, growing 
down either into the pelvic cavity alone or separating the post-parietal 
peritoneum from its attachment, even, as Ave have seen, as high up as the 
false ribs. Such tumors have no pedicle, are supplied by abundant, 
exceedingly large and tortuous vessels, and are extremely difficult of 



OPHORECTOMY. 541 

removal except by the process of incising their capsule and peeling 
them out from their bed. Of course, if the cavity should be very 
large it might be impossible to unite its walls by sutures, and it would 
have to be packed tightly with iodoform gauze, which is brought out 
of the abdominal wound, the edges of the incision in the sac being 
stitched to the edges of the abdominal wound. Olshausen, Hegar, 
Fritsch, and others, chiefly German operators, have followed the lead 
of Martin in this operation, and achieved excellent results. As yet, 
however, this method may be said to be less popular than the removal 
of the whole uterus together with the fibroids. It should be added 
that Martin and several other operators have enucleated myomatous 
tumors in this manner from the pregnant uterus, and that pregnancy 
has gone on uninterruptedly to term. 

Oophorectomy for Fibroid Tumors. — In January, 1876, Trenholme 
of Montreal first operated on a case of bleeding fibroids by the removal 
of the ovaries in order to bring about the premature menopause and 
the consequent shrinking of the uterine tumor. His case was success- 
ful. Hegar performed the same operation independently in August of 
the same year. Lawson Tait claims that he did the same operation 
in 1872, but published his claim after the reports of Trenholme and 
Hegar. The operation is now known as that of Hegar, chiefly in 
consequence of the number of times it has been performed by him and 
of his pre-eminent writings on the subject. 

Indications. — It is indicated in cases where excessive menstrual or 
intermenstrual hemorrhage is caused by a uterine tumor, or where more 
or less constant and intense pain is produced by the same factor, the 
removal of which, for reasons of inaccessibility or general debility of 
the patient, is inadvisable. Here the comparatively trifling and safe 
operation of removal of the ovaries, which entails substantially no loss 
of blood whatever, comes under consideration. It should, however, 
not be lightly undertaken, because in certain fibroids the ovaries are 
carried so far away from the median line by the growth of the tumor, 
or have become so much disorganized and are supplied with such dis- 
tended blood-vessels, that their removal is exceedingly difficult, and 
attended with almost as much danger as would be the extirpation of 
the uterus with the offending growth. Where, however, the. ovaries 
can be easily removed, together with the tubes, the effect, in our expe- 
rience, upon the hemorrhage and upon the growth of the tumor has been 
most excellent. The bleeding has ceased rapidly and usually totally, and 
a more or less speedy retrogression of the tumor has taken place. As 
regards the dangers of the operation, Hegar lost 6 patients out of od opera- 
tions ; a table prepared by Tissier gives 25 deaths out of 171 operations ; 
Lawson Tait reports 262 operations with a mortality of 1.25 per cent. 

The Curative Results as regards the Hemorrhage are given by 
Hegar as, out of 34 cases, 20 times immediate cessation of the hem- 
orrhages ; 4 times cessation after a few irregular discharges : 1 time 
persistence of the irregular metrorrhagia ; 1 time temporary menopause, 
then hemorrhage and cystic development of the tumor : 1 time meno- 
pause, then hemorrhage, requiring enucleation of the tumor ; Tissier. 
out of 146 cases, 89 of complete cessation, 21 times menopause after 



542 



FIBROID TUMORS OF THE UTERUS. 



a more or less long period of irregular hemorrhages, 10 times return 
of the menstruation after a short respite. 

Results as regards the Diminution of the Tumor. — Hegar, 22 times 
marked diminution, twice no diminution, etc. ; Tissier, 66 times rapid 
diminution, 71 times no mention (the patient is reported cured), 9 times 
no change. 

It will be seen from these statistics, which we have not sought to 
make as complete as we might easily have done with more labor, that 
the removal of the ovaries does actually arrest the bleeding caused by 
fibroid tumors and check the growth of these masses. Whether it 
would produce a diminution or absorption of very large, hard, subperi- 
toneal tumors is doubtful, since the vascular supply of these tumors is 
comparatively limited when they have once attained a large size (except 
those which develop between the layers of the broad ligament), and 
because their growth is very little influenced by the function of the 
ovaries. It is chiefly interstitial tumors of a soft variety, which cannot 
be reached through the cervical canal with sufficient ease to allow of their 
removal by this passage, and large, very vascular, also interstitial masses, 
the extirpation of which by laparotomy would prove too dangerous, which 
call for the consideration of the operation of oophorectomy. 

[Before concluding this chapter I wish to state my conviction that the 
pathological influence of fibroid tumors as a whole is over-estimated by the 
profession at large, and that many women are made unhappy by the know- 
ledge, incautiously imparted to them by their medical attendant, that they 
have a tumor of this kind. Feeling satisfied, as the result of many years' 
experience, that a large proportion of these tumors cause no serious symp- 
toms whatever, and in no way threaten the lives of their possessors, I made 
this subject a study several years ago, and found that my own observations 
during the years from 1886 to 1889 showed a record of 123 instances of 
fibroid of the uterus, or 4.14 per cent, of all the gynecological cases seen 
during that time. Of these 123 cases, but 62 required treatment of any kind 
whatsoever, in my estimation. The remaining 61 — that is, about one-half — 
afforded their owners so little inconvenience or gave so little prospect of becom- 
ing troublesome that not even a medical treatment was thought necessary. 

The methods of treatment employed in the 62 cases were — 



Uterine Fibroids j 


rom 


October 1. 


1886 


, to September 


1, 1889. 






2 


Treatment. 


Summary. 




.2 2 

go o 
— V 


CO 

2 

1 




Enucle- 
ation- 

Torsion. 


c 

> 2 

C 

4 
4 


1.2 


'V 

o 

S- 

H 




Corpus Uteri. 

Subperitoneal 

Interstitial ........ 

Submucous 

Cervix Uteri. 

Interstitial 

Polypi 


64 
31 
19 

2 

7 


6 


10 
10 


Y 

6 

2 


Y 


5 

3 


12 
22 
19 

2 

7 


52 

9 


Total 


123 


6 


3 


20 


10 


7 


8 


8 


62 


61 



FIBRO-CYSTIC TUMORS OF THE UTERUS. 543 

The following were the conclusions derived from an analysis of these 
cases, added to my experience of previous years : 

1. On general principles the rule may be laid down that fibroid growths 
of the uterus situated near the fundus uteri and showing no tendency to 
downward development, if requiring active treatment are best reached from 
the abdominal cavity. 

2. Tumors, on the other hand, situated near the internal os. and, either 
of their own accord or under the influence of oxytocic measures, showing 
an inclination to dilate that orifice and encroach upon the cervical canal, can 
almost always, after due preparation, be removed safely through the vagina. 

3. About one-half of all fibroid tumors which attract the attention of 
their possessors and come under the observation of the physician require no 
active treatment of any kind. 

4. Only interstitial and rapidly-growing subperitoneal tumors call for or 
are benefited by galvanic treatment. 

5. The removal of the hypertrophied mucous membrane of the uterine 
cavity by the sharp curette will often relieve, at least temporarily, the 
menorrhagia which is the chief symptom present in the interstitial variety. 

6. Enucleation, after splitting of the capsule by means of traction with 
the finger and some blunt instrument, usually offers a safe means of cure in 
cases of submucous corporeal and interstitial cervical tumors. 

7. In certain cases of interstitial tumors which are so situated as not to 
be amenable to the compressing influence of ergot, but still affect the gen- 
eral health by profuse, uncontrollable hemorrhage, and again in certain cases 
of rapidly-growing subperitoneal tumors in which a thin pedicle cannot 
readily be formed, the removal of the ovaries may be confidently expected to 
check the hemorrhage and growth of the tumor respectively. 

8. Laparo-hysterectomy should not be lightly undertaken, and should 
certainly never be performed merely to relieve the patient of a fibroid 
tumor which does not affect her general health and is merely inconvenient 
or unsightly, 

9. The nearer the prospective menopause, the less likely is the fibroid to 
grow or cause trouble, and therefore, ceteris paribus, the less are active or 
operative measures called for. 1 — P. F. M.] 

Fibrocystic Tumors of the Uterus. 

While we have referred to cystic degeneration of fibroids of the ute- 
rus as one of the varieties of that disease, we have not thought it con- 
venient to consider this particular form in detail in the preceding pages. 
Our reason for this was, that this fortunately rather rare variety usually 
occurs only in large interstitial or subperitoneal tumors which develop 
upward into the abdominal cavity, and so closely simulate complicated 
ovarian tumors as to mislead even the most experienced diagnostician. 
It is for that reason that we prefer to describe these tumors under a 
separate section, although we do not think them worthy of a special 
chapter. The exact pathological condition of these fibro-cystic tumors 
of the womb is not as yet fully known ; all we can say is, that we find 
large tumors of the womb, springing usually directly from the body of 
that organ by a broad attachment, in the centre of which exist one or 
more cavities containing a large quantity of usually thin yellow or col- 

1 P. F. Munde, "The Methods and Limitation of Treatment for Uterine Fibroids," 
Trans. Am. Gyn. Soc, 1880. 
ib 



544 FIBROID TUMORS OF THE UTERUS. 

loid fluid. What has caused these tumors, which were probably orig- 
inally solid, to degenerate and liquefy is, so far, unknown to us. These 
tumors may be either intra-peritoneal, as is usually the case with fibroids 
springing from the body of the uterus and developing into the abdom- 
inal cavity, or they may be extra-peritoneal, having developed between 
the layers of the broad ligament, and may then so far push up the peri- 
toneum as to encroach upon the abdominal cavity and simulate the 
intra-peritoneal variety. 

Symptoms. — The symptoms are usually those common to large 
abdominal tumors of a fibroid character — namely, abdominal enlarge- 
ment and pressure upon neighboring organs. As a rule, these tumors 
do not cause profuse menstruation or affect the health of the indi- 
vidual. 

Frequency. — This fibro-cystic degeneration is fortunately not very 
common; still, a sufficient number of cases occur to give almost any 
physician who makes gynecology a specialty an opportunity to see a 
number of them and to test his pdwers of diagnosis. 

Differential Diagnosis. — The chief difficulty in the diagnosis of 
these tumors is to distinguish them from large multilocular cysts of the 
ovary. The diagnostic signs pertaining to the latter apply almost with- 
out exception to the former. As a rule, in tumors springing from the 
ovary the length of the uterine cavity remains normal ; that is, the 
sound enters only to a depth of two and a half inches ; in tumors 
springing from the uterine body, however, the length of the uterine 
cavity is very often more or less increased, up to five, six, or more 
inches. This differential sign may be of value in interstitial uterine 
growths to distinguish them from certain kinds of ovarian tumors ; but 
it unfortunately fails in fibro-cysts of the uterus, which grow away from 
the uterine body and leave the cavity of the organ of entirely normal 
length. The examination of the fluid of a fibro-cyst of the uterus 
removed by aspiration unfortunately gives no distinct evidence of the 
character of the tumor. It is usually, as remarked, of a light straw 
color, and the so-called ovarian corpuscle of Drysdale is not found in 
it. The fluid also coagulates on standing, like the serous fluid removed 
from the peritoneal cavity in cases of abdominal dropsy. But these 
signs are uncertain and not to be relied upon. One sign upon which 
we lay the greatest stress is that in fibro-cysts of the uterus the general 
health of the patient is usually not affected. There is, in fact, none of 
the cachexia which is very truly considered a distinctive symptom in the 
advanced stages of ovarian tumors. Our experience has led us to feel 
that in any case of a large abdominal cystic tumor which had been 
growing for a certain number of years, if the health of the patient is 
entirely unaffected, her color good, her strength undiminished, we 
should, unless the physical examination decidedly pointed to ovarian 
disease, proclaim ourselves in favor of a fibro-cyst of the uterus. The 
diagnosis, however, between these two conditions is so very difficult to 
make that no surgeon who has had the opportunity to perform a num- 
ber of abdominal sections for ovarian and uterine tumors can deny, if 
he is willing to own the truth, that he has failed to discover in one or 
more instances that a fibro-cvst of the uterus was such until he had 



TREATMENT. 545 

opened the abdominal cavity and explored through that opening the 
attachments of the tumor. Spencer Wells speaks of a darker hue of 
the cyst-wall, which might lead the operator to suspect that he is not 
dealing with an ovarian tumor ; and we can corroborate his state- 
ment. 

Treatment. — Ordinarily, the treatment of fibro-cysts of the uterus 
does not differ from that of large subperitoneal fibroids of that organ 
which under certain conditions, as already described, warrant or call for 
operative removal. As we have already stated, the diagnosis is usually 
not made until the abdominal cavity has been opened. In several such 
instances we have been tempted to close the incision and leave the tumor 
alone as soon as we discovered the error of diagnosis. We regret to say 
that we did not do so — that we attempted the removal of the tumor ; 
found its attachment to be such that this could be effected only after 
long and patient labor and with great difficulty. The patients suc- 
cumbed to the shock of the prolonged operation. After evacuating 
the fluid, if this is decided to be done, or if this has been done acci- 
dentally before the correct diagnosis was made, the removal of the sac, 
with as much of the uterus as seems necessary, should be performed on 
the same principles as already indicated. 

In cases where the attachments of the fibro-cyst are so extensive, or 
its vascularity so great, as to render its complete extirpation too hazard- 
ous, the cyst might be opened by a large incision, the fluid thoroughly 
evacuated, and the sac-wall stitched into the abdominal wound, as is 
done with unremovable cysts of the broad ligament and intra-ligament- 
ous ovarian cysts. The cavity is then packed with iodoform gauze, and 
allowed to shrink and fill by granulation. We think this method far 
preferable to the removal of the whole tumor at all hazards. Any 
redundancy of the sac can be removed before it is stitched to the 
abdominal wound. 

Removal of the fluid by tapping, repeated when necessary, may 
be allowed in these cysts when they cannot be removed. In ovarian 
cysts, as will be stated later on, tapping is no longer thought proper 
treatment under any circumstances, since removal can usually be 
effected. 

Synopsis of Operative Treatment of Different Varieties of Uterine 
Fibroids. — The following table from Pozzi's recent work on gynecology 
seems to us very comprehensive and instructive, and substantially 
agrees with our own views : 

Large and non-vascular pedi- f Ligature or sutures with silk or catgut, and drop- 
cies (without opening the -j ping of the pedicle according to the method of 
uterine cavity). ( Schroeder. 

Hollow and non-vascular pedi- f (L If \ ] ] e P + edicl ? is of sufficient length, extra-perito- 
cles (with opening of the , ^. treatment, according to Hegar 
uterine cavitv) ' insufficiently long, mixed treatment — methods 

^'' { of Woelffer-Hacker or Saenger. 

f a. Sufficiently long, extra-peritoneal treatment, after 

Ilegar. 
I b. Insufficiently long, mixed treatment with elastic 
Very vascular pedicles. ^ ligature, after Saenger. 

. Excessively short, intra-peritoneal treatment with 
elastic ligature buried, according to Olshausen, or 
total hysterectomy, after Bardenheuer. 



546 



UTERINE POLYPI. 



No pedicle ; interstitial or 
submucous tumors, easy of 
enucleation. 



No pedicle ; tumor enclosed 
in the pelvic cellular tissue 
or between the layers of the 
broad ligament. 



\ a. Lateral portions of the uterus very vascular, supra- 
vaginal hysterectomy and extra-peritoneal treat- 
ment of the pedicle, after Hegar. 
. Posterior or anterior surface of the uterus slightlv 
vascular, enucleation, suture of capsule, and drop- 
ping of uterus (method of Martin). 
. The same, enucleating, opening of the uterine cav- 
ity during enucleation, supravaginal hysterectomy, 
extra-peritoneal treatment, after Hegar. 

\ a. Small tumor easily enucleable, enucleation, deep 
suture of the sac, no drainage. 

b. Large tumor easily detachable from the uterus, 
large cavity or pocket bleeding freely, enucleation, 
pressure, resection, and superficial suture of the 
pocket and drainage by the vagina (Martin), or 
drainage through the abdominal wound, according 
to circumstances ; in case of need tamponade with 
iodoform gauze ; uterus left uninjured. 

c. The same with firm and bleeding attachments to 
the lateral portions of the uterus, supravaginal 
hysterectomy, treatment of pedicle as above, suture 
and drainage of the sac, with or without tampon- 
ade. 



CHAPTER XXXVII. 



UTERINE POLYPI. 



A uterine polypus is a fibroid tumor of the uterus which has grad- 
ually been forced down into, or even out of, the uterine cavity by means 
of the contractions of the organ, and which then is connected with its 
original site by a comparatively small attachment known as a pedicle. 
The polypus is covered with uterine mucous membrane, and perhaps 
also by a certain amount of uterine muscular tissue. Its attachment 
may be very small, not broader than that of the little finger, or equal 
in diameter to the largest breadth of the tumor. 

Other pediculated masses projecting into the uterine cavity are 
designated by the name of polypus, but are not truly such : they are 
the result of an accumulation of blood-fibrin around a nucleus spring- 
ing from the placental site after a confinement at term or a miscarriage. 
They are composed of fibrous tissue, are not supplied with blood-vessels, 
and are not firmly attached to or incorporated with the tissue of the 
uterus. They are simply compressed blood-clots depending from the 
placental site. To distinguish them from the fibrous or true polypi 
these blood-clots are called fibrinous polypi. In fact, they are not real 
polypi at all, and are mentioned here only for the purpose of distin- 
guishing them from the true variet} 7 . 

History. — That these formations occur was known in remote antiq- 



GLANDULAR POLYPI. 



547 



Fig. 260. 



uity of medical history ; but little attention was paid to them and their 
exact origin and nature was not understood. 
Still, the name of polypus has clung to them 
for hundreds of years, and has become a 
familiar term with the laity. The revival of 
the French school of medicine in the seven- 
teenth century helped to throw light on this 
subject, and since then gradually it has 
become so familiar that the true nature of 
these tumors is no longer in doubt. 

Varieties. — There are two varieties of 
uterine polypi — glandular and fibrous. First, 
cystic and hypertrophic enlargement of the 
glands of the cervical cavity, which eventu- 
ally may dilate the cervical canal, escape 
from the external os, and grow down even as 
far as the vaginal orifice. Second, those 
springing from interstitial or submucous 
fibrous or myomatous tumors which have 
gradually grown or been forced into the 
uterine cavity, and in virtue of the forma- 
tion of a pediculated attachment have assumed the character of a 
polypus. 




Glandular Polypi (De Sinety). 



Fig. 261. 



Glandular Polypi. 

Pathological Anatomy. — These polypi, as already indicated, are 
merely hypertrophic cervical glands filled with the viscid fluid normally 
secreted by those glands, and 
usually associated with a certain 
amount of hypertrophy of the 
mucous lining of the cervical 
canal. They are either unilocular 
— that is, composed of one enlarged 
gland only — or more usually mul- 
tilocular, in accordance with the 
racemose character of these glands. 
They may spring either from the 
cervical cavity proper at any point 
between the external and internal 
orifices or from the vaginal surface 
of the uterus itself. They are 
benign in character, and seldom 
attain a size larger than that of a 
small egg, their usual size being 
that of a bean. Once removed, 
the same polypus never returns, although a similar one may appear in 
consequence of the enlargement of another cervical gland. 

Adeno-myxo-sarcoma of the Cervix. — Very rarely these glandular 
polypi develop to an enormous size, so as to not only fill the vagina. 




Glandular Polypi (IleitzmannV 



548 



UTERINE POLYPI. 



but even protrude from the vulvar orifice. Of the few cases of this 
kind reported, the larger number proved to be eventually of a semi- 
malignant type, the central portions having assumed a sarcomatous 
formation, and their removal was only followed by a temporary relief; 
a speedy recurrence of the growth and the death of the patient from 
exhaustion being the result. 

The nature of these tumors is partly glandular, partly colloid in con- 
sequence of the peculiar viscid character of the fluid they contain, and 
partly malignant or sarcomatous. They have therefore been called 
adeno-myxo-sarcoma or myo-sarcoma striocellulare uteri (Pernice 1 ). 
We have both chanced to see each a typical case of this rare disease. 
In the last edition of this book, on p. 560, appears a diagram of a 
tumor of this kind seen by Thomas (Fig. 262), the length of which 

was four and a. half inches. It 
Fig. 262. sprang from the inner wall and lip 

of the cervix, caused no symptoms 
except leucorrhoea and pelvic neur- 
algia, and was not known to exist 
until difficulty in sexual intercourse 
caused the patient to apply for ex- 
amination. The mass was examined 
after removal by Dr. F. Delafield, 
and found to consist of enlarged 
cervical follicles. It was removed 
with great ease by the ecraseur; 
whether it ever returned or not is 
not known. A comparison with the 
other tumors mentioned in this list, 
particularly the absence of cachexia, 
would seem to show that this growth 
was benign. The other case was 
seen by Munde' in 1888, and is 
fully described in the February 
(1889) number of the American 
Journal of Obstetrics. The pa- 
tient was a young girl of nineteen, 
who for two years had suffered 
from a profuse watery vaginal dis- 
charge. The vaginal canal was 
found completely filled with a nod- 
ular, slimy, friable tumor which 
even protruded between the labia. 
The centre of the tumor seemed firm. It was removed with the con- 
strictor wire by Munde, and it Avas then found that the vaginal vault 
contained a number of cysts filled with gelatinous fluid. The fluid 
oozing from the tumor resembled jelly, or, perhaps better, a mass of 
crushed grapes. The supposition that the centre of the tumor was 
solid was confirmed by the wire loop, which creaked audibly on cut- 
ting through it. The mass sprang from the whole cervix, the body 

1 Virchow's Arckiv, July 3, 1888. 




Glandular Polypus (Thomas). 



GLANDULAR POLYPI. 549 

of the uterus being entirely uninyolved. The microscopic examination 
showed that this mass was undergoing sarcomatous degeneration in its 
central portions. The tumor returned within two months, and the 
patient soon died from exhaustion. In Pernice's article we find first 
the report of his own case (Fig. 263), which resembled very much 
the one reported by Munde (first removal by excision, two months 
later recurrence of the tumor, removal by the galvano-cautery wire, 
nine months later laparotomy for large abdominal tumor, death of 
patient). Microscopical examination showed myxoid degeneration of 
the first tumor, sarcomatous degeneration of the second and third 
tumors. 

Munde two years ago 1 (1889) w T as able to find only nine cases in 
all of this singular and destructive disease — namely, Thiede, Rein, 
Spiegelberg, Winckel, Weber, Thomas, Pernice, and Munde*. We 
believe that Fenger of Chicago has since reported an additional case 
of this kind. 

Symptoms. — The symptoms produced by glandular polypi of the 
cervix are usually those of a profuse leucorrhoeal, more or less acrid, 
discharge or of a bloody flow, which may, even in very small tumors 
of this kind, be eventually so profuse as to cause decided anaemia. 
We have seen glandular polypi not larger than a bean almost exsan- 
guinate the patient. The irritant character of the discharge may 
produce a vaginal and vulvar irritation sufficient to render the patient 
miserable ; and it is this symptom which usually first induces her to 
seek professional advice. The semi-malignant variety of glandular 
polypi above mentioned makes itself known by a rapid deterioration 
of the general health of the patient, produced by the excessive sero- 
sanious vaginal discharge. 

Physical Signs. — The finger detects a small growth dilating the 
external os or protruding from it. Occasionally it may occupy the 
larger part of the vaginal canal. We do not remember ever having 
seen one larger than a hen's egg. Examination produces more or less 
hemorrhage, but is not attended with any special pain. The uterine 
cavity is not elongated and the uterus not enlarged. The attachment 
to the cervical canal can very easily be ascertained by means of the 
sound or by inspection through the speculum. 

Course and Termination. — Unless removed, these little tumors will 
probably remain indefinitely, although not infrequently the slender 
pedicle becomes torn by accident or sloughs through, and the tumor 
is expelled spontaneously. 

Progyiosis. — The prognosis is always good, except in the mvxo- 
sarcomatous variety already described. A cervical catarrh invariably 
exists in connection with these polypi, and may indeed be said to have 
been the original cause of their formation. 

Treatment. — The treatment is exceedingly simple, and consists in 
grasping the polypus with an ordinary dressing-forceps or a broad poly- 
pus-forceps and twisting it around until the pedicle is severed. In 
order to cure the primary disease — that is, the cervical catarrh — the 
use of the sharp curette, followed by nitric acid, as described in the 

1 Loc. eit. 



Fig, 263. 




A Grape-like Myxosarcoma (.Strioceliulare Uteri Pernice) 



FIBROUS POLYPI. 551 

chapter on Cervical Endometritis, is advisable. No more brilliant, 
speedy, and permanent success can be achieved in the department of 
gynecology than by the removal of a polypus, whether of the granu- 
lar or fibrous variety, and the immediate cessation of the symptoms 
and the rapid return of the patient to health. 

Fibrous Polypi. 

These tumors are of vastly greater importance than the compara- 
tively insignificant ones just described. Undoubtedly, it is the thing 
to be desired in all cases of fibroid tumors which show a tendency to 
grow toward the uterine cavity that they should eventually — and the 
sooner the better — become pediculated and present themselves at or 
through the external orifice of the uterus, so as to permit of their easy 
and safe removal. It should, therefore, be our object, whenever such 
a possibility seems to present, to endeavor to force the fibroid into the 
uterine cavity and toward the vaginal canal by means of all agents 
which excite uterine contractions and dilate the uterine canal. Such 
are — ergot, the faradic current, dilatation and discission of the uterine 
canal, and tamponade of the vagina. These methods have already 
been discussed in the previous chapter. 

Pathological Anatomy. — A fibrous polypus is covered by mucous 
membrane, more or less muscular fibre, and is composed of fibrous tissue, 
intermixed more or less with muscular elements of the uterus. A 
few instances are on record where the central portion of the polypus con- 
tained fluid, evidently in consequence of a myxomatous degeneration of 
a portion of the fibroid. Such polypi have been described as hollow 
polypi, but they are of no special pathological significance, being inter- 
esting only in that they may possibly be mistaken for an inverted ute- 
rus. Such a mistake should, however, not be made if the differential 
points between inversion and polypus are borne in mind, chiefly the 
presence of the body of the uterus above the symphysis pubis in poly- 
pus, and its absence in inversion. 

The attachment of fibrous polypi may be at any point of the ute- 
rine cavity and of variable thickness. If a fibroid polypus has es- 
caped into the vagina, usually its attachment to the uterine wall is 
comparatively limited ; if, however, the polypus springs from near 
the fundus uteri, its insertion may be as broad as the diameter of the 
polypus. 

The size of these tumors varies greatly, from a hickory -nut to a foetal 
head, or even somewhat larger. We have seen a number of cases in 



Explanation of Fig. 2G3 (on page 550). 

1. Cervix uteri, with tumor hanging from it (natural size). Sound passed through cervical 
canal. L, a line of excision : a, a, and b, berry-like growths ; c, fragments of delicate epithelial 
membrane covering a number of the berries. 

2. Section of a berry hardened in alcohol (Beneche, Oc. 3, Obj. 7) ; a, type of stroma : b. numer- 
ous interlacing striated muscular fibres ; c, fibres in which the strise cannot yet be seen : at times, 
<\ these fibres are cut transversely. 

:;. Cells from the third tumor, "fresh specimen ; <r. stellate cell with numerous nuclei : b. spin- 
dle-cells with one long nucleus: at c the ends of the spindle fatty; <f, spindle-cells, with 
several nuclei ; e, fatty debris with free nuclei, partly fatty. 

4. striated spindle-cell from the first tumor. 

5. Muscle-fibres from a five to six weeks' old embrvo. 



552 



UTERINE POLYPI. 



which we have been obliged to use the obstetric forceps, and in nul- 
liparae split the perineum before we could extract the polypus (Fig. 268). 
With the exception of the greater muscular effort required, and there- 
fore pain experienced in the expulsion of these large tumors, they do not 
cause very much more bleeding than the smaller ones. 

Symptoms. — The chief symptom produced by a fibrous polypus of 
the uterus is hemorrhage, not only during the menstrual period, but at 
any other time. If the polypus is still 
situated within the uterine cavity, and 
is exciting that organ to efforts of ex- 
pulsion, there will be in addition severe 
labor-like pains which, to women who 
have borne children, recall the contrac- 
tions experienced during childbirth. 
These pains are more frequent at the 
time of the approaching menstrual 
period, and of course their severity is 
in proportion to the size of the tumor 
and to the strength of the efforts re- 
quired by the uterus to expel it. 

Fig. 264. 




Fig. 265. 




■*\ v : -^||y^ 




mm, 
fiff f\ 









Polypus dilating External Os (Heitzmann). 



Complete Laceration of Perineum 
caused by Extraction of Large Ute- 
rine Polypus with Obstetric Forceps. 
The laceration was at once sewed, 
and healed readily. Patient was a 
virgin 41 years of age. Polypus size 
of fcetal head. (From a case of Munde.) 



Pains in the lower part of the abdomen and back, bearing down, a 
feeling of weakness, and want of support in the pelvis are symptoms 
which will naturally accompany these tumors. The bleeding is very 
often so severe in these cases that the women become bedridden and 
utterly exsanguinated, although death seldom occurs from the hemor- 
rhage, the lulls between the attacks being usually sufficient to enable 
the patients to recover strength and blood enough to resist the next 
attack. 

Physical Signs. — Examination by the finger reveals decidedly dif- 
ferent conditions, according as to whether the tumor is still situated in 
the uterine cavity or has already entered the cervical canal and is dila- 
ting the external os, or whether it has escaped into the vaginal canal. 



DIFFERENTIAL DIAGNOSIS. 



If still situated within the uterine cavity, the external orifice may be 
only sufficiently wide to allow the insertion of the index finger up to or 
through the internal os, or the diagnosis may have to be made by the 
uterine sound, which on passing through the internal os first meets an 
obstruction, and then, on its direction being slightly changed, passes 
over that obstruction until it reaches 

the fundus. The cavity of the ute- Fi g- 267. 

it must be remembered, is al- 



ways elongated in these cases 




Polypus filling Vagina. 



Polypus producing Partial Inversion of the 
Uterus. A-B shows level of inverted .peri- 
toneum. 



the tumor has already dilated the external os, the diagnosis is of course 
very easily made by the examining finger, and the more so if the mass 
has escaped into the vagina. The point of attachment of the polypus 
is not always easy to determine unless the finger can be passed into 
the uterine cavity. 

Differential Diagnosis. — In order to make a correct diagnosis of 
an intra-uterine polypus, the uterine canal, if not sufficiently dilated for 
the introduction of the finger, must be rendered accessible to it by 
means of tupelo tents, aided, if necessary, by the bilateral division of 
the vaginal portion of the cervix and the internal os. If the polypus 
has escaped into the vagina and its pedicle more or less fills the cervical 
canal, it may so closely simulate an inversion of the uterus, especially 
if the pedicle has become attached to the adjacent walls of the canal. 
that the true diagnosis may become exceedingly difficult. This is the 
more the case if, as very frequently happens, the expulsion of the tumor 
has caused a partial inversion of that part of the uterine wall to which 
it is attached. The introduction of the sound into the uterine cavity, 
careful bimanual examination under anaesthesia with reference to ascer- 



554 



UTERINE POLYPI. 



Fig. 268. 




taining the location of the body of the uterus, and the absence of pain 
or inflammatory reaction following a protracted examination in case of 
a polypus, as against the possible presence of these consequences in case 
of inversion, will usually prevent the practitioner from making a mis- 
take. 

Course and Termination. — Fibrous polypi will usually remain where 

they are until removed. Occasionally the 
forcible contraction of the uterus will cause 

the sloughing of the tumor or the detach- 
es o 

ment of the pedicle, and the mass may then 
gradually work its way out or be expelled 
from the vagina by the contractions of 
that canal. At times the tumor, if at- 
tached to the fundus uteri, may be ex- 
pelled, inverting during that process the 
whole uterus in consequence of the trac- 
tion on the point of attachment. 

Prognosis. — This is always good, since, 
as we have already mentioned in regard to 
glandular polypi, once discovered, their 
removal is usually easy and the recovery 
rapid. Only in cases where the polypus 
is attached to the fundus is the prepara- 
tory treatment required to bring the tu- 
mor within reach for removal tedious, 
painful, and to a certain extent danger- 
ous. 
Treatment. — The old division of treatment into palliative and cura- 
tive is no longer tenable or practised. A polypus of the uterus, once 
discovered, should be removed as soon as it can safely be done. As 
already mentioned under Fibroids when speaking of the submucous 
variety, the one essential factor is sufficient dilatation of the uterine 
canal to permit the easy accessibility of the tumor to the fingers and 
the instruments necessary for its detachment. As a rule, Nature pre- 
pares the way very satisfactorily for the easy removal of uterine polypi by 
forcing them clown into and through the cervical canal, so that their pedi- 
cles can be reached without great difficulty. In former days complicated 
and dangerous instruments were devised and employed for the purpose 
of dividing the pedicle of the polypus within the uterine cavity, either 
by a knife (polypotome), or by a wire rope or steel chain (constricteur or 
ecraseur) passed around the pedicle, or the galvano-cautery wire was 
employed for the same purpose. Nowadays we have abandoned these 
complicated and unnecessary contrivances, finding that we can remove 
any polypus, after thorough dilatation of the uterine canal, by seizing 
it with vulsella forceps and drawing it into or even out of the vagina 
until its pedicle is easily reached. This can either then be cut shortly 
off and the uterus replaced, or, what is far more safe and what we most 
decidedly recommend, is to seek the line of demarcation between the 
tissue of the tumor and the uterine wall, and with the finger, scalpel 
handle, or blunt closed scissors effect a superficial separation between 



Fibrous Polypus attached to Fundus 
Uteri. Suitable case for avulsion 
with Goodell's long forceps. 



TREATMENT. 555 

uterus and tumor, and complete the detachment with the fingers. In 
this way we will avoid doing what has happened to most excellent ope- 
rators — namely, the removal of a portion of the uterine wall, even to the 
extent of injuring its peritoneal covering. (See Fig. 267.) Whatever 
inversion of the uterine body has taken place during the removal of the 
polypus should then be at once replaced. The uterine cavity should then 
be irrigated with a 1 : 10,000 solution of bichloride, carefully dried, and 
packed lightly with iodoform gauze. This latter precaution is not ne- 
cessary except in cases where the polypus sprang from a point high up 
in the uterine cavity. When the point of insertion of the polypus was 
in the cervical canal, a mere tamponade of the vagina with iodoform 
gauze suffices. The uterus itself provides against hemorrhage by an 
immediate and thorough contraction of its walls; hence the hemostatic 
means of removal of polypi above mentioned, as well as the employ- 
ment of hemostatic pressure after the operation, are not required. It 
is merely as a matter of precaution in case we are obliged to leave the 
patient that the tamponade with iodoform gauze is recommended. 

The preparation of the uterine canal in order to render the polypus 
accessible may require some time. We have been obliged to dilate 
with tupelo tents a dozen times or more, divide bilaterally the cervical 
canal, and administer ergot during a period of nearly two months before 
we could finally reach the tumor with vulsella and grasp it sufficiently 
firmly to draw it through the external os. It is better in such difficult 
cases, where the polypus springs from the upper portion of the uterine 
cavity, to be patient and gradually prepare the canal as indicated, 
rather than to attempt to force the removal of the tumor at the risk of 
injuring the uterus or producing a perhaps fatal peritonitis or septi- 
caemia. The patient need not lose strength in consequence of this pro- 
tracted preparatory treatment, since all hemorrhage can be thoroughly 
controlled by steady tamponade of the vagina or even uterine cavity 
with iodoform gauze, repeated every three or four days as occasion 
may require. The piecemeal removal of fibrous polypi is scarcely 
necessary except where the tumor is so large that it cannot be removed 
entire. We have never met with a polypus of such size, since tumors 
requiring mutilation before they can be extracted seldom become 
polypoid. 

Fibroid polypi never undergo malignant degeneration. 

Before concluding this chapter we would again emphasize the 
advice given as regards the invariable employment of the practice of 
enucleating the tumor after careful incision of its capsule near the point 
of attachment to the uterine wall, instead of blindly cutting it off at 
the apparently most favorable point with a knife or scissors. We our- 
selves have several times narrowly escaped committing a blunder of 
this kind which we should have greatly deplored, and we have seen 
several instances in the hands of most expert colleagues where only 
repeated examinations at different intervals and the final adoption of 
this method of enucleation saved the operators from both an error in 
diagnosis (inversion) and from injuring the uterine wall. A uterine 
polypus once thoroughly removed never returns : a second tumor in the 
same case may appear at some later period, and is simply a new fibroid 



qd6 adenoma axd sarcoma of the uterus. 

which has worked its way down into the uterine cavity, not the return 
of the one which was removed. It is well to make this point clear to 
patients, for fear of their blaming us with having performed an incom- 
plete operation when they find that a new polypus has developed. 



CHAPTER XXXVIII. 
ADENOMA AND SARCOMA OF THE UTERUS. 

Adenoma. 

Definition. — By adenoma of the mucous membrane lining the cavity 
of the uterus is meant hypertrophy of the glands normally found in 
different parts of that cavity, with or without an increase of their fluid 
secretions. The various elements of the glands — superficial and lining 
epithelia and stroma — may all be more or less hypertrophied, and 
accordingly there may be either a diffuse enlargement of the mucous 
membrane or of its individual portions. 

Varieties : Adenoma of the Cervix. — This has already been 
described under the head of Glandular Polypi in the preceding chap- 
ter, to which we refer. 

Adenoma of the Body. — In the cavity of the body of the uterus 
the adenomatous degeneration may manifest itself either in the form 
of a minute enlargement of the numerous glands or in the production 
of actual tumors which dilate the cavity of the organ and produce 
decided pathological symptoms. 

Pathology. — We confine ourselves entirely to the description of the 
pathology of the adenomatous degenerations above the internal os, 
those below that point having been described in 
Fig. 269. the previous chapter. The most common form 

of this disease is the hypertrophy of a certain 
number of the uterine glands, varying from a 
few scattered here and there throughout the cav- 
ity to such a quantity as to completely occlude 
the passage. (See Figs. 153 and 260.) 

This hypertrophy may be confined to only a 
certain number of glands, or it may extend 
throughout the whole tissue of the mucous mem- 
AdeD (Winckeu rui ' brane of the uterus, being then called diffuse 
adenoma of the endometrium. When but a cer- 
tain number of glands are enlarged and projecting into the uterine 
cavity in the shape of small polypoid tumors varying from the size of a 
small shot to a canary-seed, the condition is spoken of as polypoid 
degeneration, villous or hemorrhagic endometritis, or. very commonly 
in this country, granulations of the uterine mucous membrane. This 




CA USES— PROGNOSIS. 557 

is the most common form, and the one which we are usually called 
upon to treat as a cause of profuse menstruation. It is not malignant 
in character, and while after the removal of the hypertrophied glands, 
if the action of the mucous membrane is not kept under proper control, 
they may return once or oftener, they almost always remain benign, and 
the prognosis is correspondingly good. 1 

At times the hypertrophy of the mucous glands of the uterine cav- 
ity proper becomes excessive ; a number of glands combine and develop 
into actual tumors which may attain the size of a bean or even larger. 
They usually occur in women advanced in life, and are very liable to 
undergo a sarcomatous degeneration, which of course renders their 
removal a merely temporary cure. It is therefore advisable in all 
cases of diffuse adenoma of the body of the uterus to subject the speci- 
mens removed to a microscopical examination, and to decide upon 
prognosis and treatment accordingly. 

Causes. — Any persistent hyperemia or irritation of the mucous 
membrane of the uterine cavity will tend to produce the glandular 
enlargements here described. Thus chronic endometritis, subinvo- 
lution, hyperplasia, displacements, laceration of the cervix (a very 
common primary factor in the production of villous endometritis), 
finally, possibly, gonorrhoeal infection, — may all exert a powerful influ- 
ence in stimulating the uterine glands to the hyperplastic development. 

Symptoms. — The first symptom is an excess of the normal secretion 
from the uterine cavity ; the next, a change in the secretion from a 
serous, non-irritant discharge to one that irritates and erodes the parts 
over which it passes ; and the third and final, the production of profuse 
menstruation. These symptoms are not confined by any means to 
women who have borne children, but may be found as the result of 
this disease in virgins or nulliparous women, and even in women who 
have already passed the change of life. The chief symptom undoubt- 
edly is the profuse menstrual flow for which most patients seek medical 
advice. 

Differential Diagnosis. — The diagnosis is easily made in the case 
of villous endometritis by passing a small wire curette into the uterine 
cavity (as already fully described under the heading of Endometritis, 
to which chapter we refer for further particulars). The absence of any 
other sign than the mere anaemia following the profuse menstruation 
will usually enable us to eliminate the probability of malignant disease 
of the endometrium, but when we find the uterine cavity occupied by 
actual tumors which cannot be removed by the small blunt curette, ami 
which on dilating the canal with tupelo tents and introducing the finger 
present a suspiciously soft touch, it is always best to subject a portion 
of the specimens removed to the microscope, since masses of this kind 
are very apt to degenerate into the other form of intra-uterine disease 
about to be mentioned in this chapter — namely, sarcoma. 

Prognosis. — While diffuse polypoid adenoma of the small variety 
(villous endometritis) may recur once or more times, and still not be 
malignant, when tumors of the larger variety return the prognosis is 
usually unfavorable, because their malignancy then remains long in doubt. 

1 See Fig. 153. 



55! 



ADENOMA AND SARCOMA OF THE UTERUS. 



Frequency. — Villous endometritis, as already stated, is exceedingly 
frequent. Diffuse papillary adenoma of the body, with the develop- 
ment of larger tumors is, however, fortunately comparatively rare. We 
say "fortunately," because, as we have already mentioned, such tumors 
are very liable to become malignant. 

Treatment. — The same treatment applies to both the minor and the 
major varieties of this disease — namely, the complete, thorough, and 
permanent removal of the pathological growths. This is effected, in 
the variety known as polypoid or villous endometritis, by means of the 
blunt, or in bad cases the sharp, curette, with the immediate application 
of strong tincture of iodine or iodized phenol. In larger growths, how- 
ever, the curette, even of the sharp variety, will usually not suffice, and 
the uterine cavity requires to be thoroughly dilated by tents and the 
growths to be removed by the galvano-cautery loop or by twisting off 
with forceps (see Morcellement, under Fibroids), followed by the sharp 
curette and the thorough swabbing of the uterine cavity with strong 
nitric acid. It is but necessary to mention that the causes of the 
formation of these growths already referred to should never be neglected, 
since upon their removal depends the permanent cure of the disease. 

Sarcoma. 

History. — For a number of years there were found scattered through 
medical literature descriptions of a tumor growing from the cavity of 
the uterus which for a time simulated true myo-fibroma, and then grad- 



Fig. 270. 



Fig. 271 





Sarcoma of Mucous Membrane of 
Body of Uterus. 



Sarcoma of Stroma of Bodv of Uterus 



ually developed more or less pronounced malignant traits. Such tumors, 
after their removal as apparently perfectly benign fibrous growths, 
returned again and again, and finally terminated fatally. Besides, 
contrary to the usual course of fibroids, they showed a tendency to break 
down, bleed, become gangrenous, and produce septic infection. The 
older authors, Pasret, West, Oldham, and others, called such growths 



SARCOMA. 559 

malignant fibrous tumors, recurrent fibroids, and myeloid tumors. 
Virchow was the first to give the name of sarcoma — derived from the 
Greek cap*, flesh — to these growths, and to clearly define the disease 
and place it in a distinct class, apart both from the non-malignant 
fibroids and the rapidly malignant cancerous developments. 

Definition, Pathology, and Frequeyicy. — Sarcoma, according to Vir- 
chow, distinguishes itself by a rapid growth of connective tissue, cha- 
racterized chiefly by the predominant development of cellular elements. 
The various component parts of the growth possess the characters of 
incomplete, rudimental, or embryonic development, and not those of 
perfect tissue microscopically. There are scattered throughout the 
stroma of connective tissue accumulations of cells with large nuclei, 
some of the cells being long, others spindle-shaped, and, according to 
the predominance of the one or other of these cells in a tumor, it is 
called either a round-celled or a spindle-celled sarcoma. The difference 
between sarcoma and carcinoma is that in sarcoma the cells are mixed 
indiscriminately with the connective tissue or stroma, not being con- 
gregated in masses at any one spot, whereas in carcinoma the arrange- 
ment of the cells is in accumulations or nests surrounded by the con- 
nective tissue. As a result of this microscopical arrangement the 
sarcoma grows more slowly, becomes less easily disintegrated and 
broken down, and therefore reaches a fatal termination at a much 
later date than does the carcinoma. Sarcoma is not often found in 
the cervix uteri : starting, when it does occur there, usually in the 
stroma of that part. In this respect it differs from cancer of the cer- 
vix, which is very much more common than cancer of the body of the 
uterus, and usually starts in the mucous membrane. On the other 
hand, sarcoma of the body of the uterus more frequently commences 
in the mucous membrane than in the stroma of the organ. There are 
very many subdivisions of sarcoma which apply as well to other por- 
tions of the body as to the uterus. In a general way, sarcoma may be 
divided into soft and hard, according to Virchow, who gives as other 
subdivisions a fibro-sarcoma, a myxo-sarcoma, a glio-sarcoma, a melano- 
sarcoma, a chondrosarcoma, and an osteo-sarcoma. Of these varieties, 
only the fibro-sarcoma, myxo-sarcoma, and possibly melano-sarcoma, 
concern us, and these are not confined to the uterus, but are found in 
various pelvic organs, from the vulva inward. 

Sarcoma of the uterus is by no means as frequent as carcinoma. 
Precise figures it is not in our power to give. 

Causes. — These are as uncertain and doubtful as those usually given 
for carcinoma ; possibly the retention of placental fragments following 
an abortion may be the starting-point of the malignant degeneration, 
or the disease may gradually develop from a hyperplastic villous endo- 
metritis ; but, as in carcinoma, there must probably be some as yet 
mysterious and unknown constitutional predisposition which in some 
cases causes a malignant development under circumstances which in the 
other cases would speedily terminate in recoverv. 

Symptoms. — The symptoms of sarcoma of the uterus are — first, a 
watery, then sero-sanguineous, and finally bloody, discharge which grad- 
ually becomes offensive, is mixed with mure or less detritus or tissue- 

36 



560 ADENOMA AND SARCOMA OF THE UTERUS. 

shreds, and in course of time produces a marked debility of the patient. 
Severe pain is usually experienced in the suprapubic region when the 
disease is pretty well advanced. While at first the sanious and even 
bloody discharge has not attracted any particular attention, the deteriora- 
tion of the patient's general health at last causes her to seek professional 
advice. 

Physical Signs. — If the disease is situated at the cervix or within 
the cervical cavitv, the examining finger easily makes the diagnosis of 
a nodular, readily-bleeding enlargement of that part. The microscope 
will settle the diagnosis ; but, unfortunately, as already mentioned, the 
disease is usually limited to the body of the uterus, and only after dila- 
tation of the canal and the passage of the finger into the uterine cavity 
can a presumptive diagnosis be made. The finger will detect in the 
cavity of the uterus a mass of spongy, more or less friable, readily- 
bleeding tissue springing diffusely from the uterine wall, on removal of 
which by means of the finger or the curette the microscope makes the 
diagnosis. The uterine body is more or less enlarged in proportion to 
the amount of diseased growth contained in its cavity. Occasionally 
the mucous membrane is found perfectly smooth and unaffected, but the 
body of the uterus is enlarged, and at one point or the other a tumor is 
felt within the uterine wall, which has ulcerated internally, and from 
which the discharge emanates. The disease is then not one of the 
uterine mucous membrane, but of the uterine muscular tissue. In rare 
instances the whole uterus appears to be infiltrated with sarcomatous 
nodules. 

Differentiation. — In the early stages the disease may be mistaken 
for retained placental fragments, for a uterine polypus, or, if of the 
interstitial variety, for a fibroid. Later on it may simulate a slough- 
ing fibroid, but the one disease w T ith which it may be most readily con- 
founded is true cancer of the mucous membrane or body of the uterus. 

Course, Duration, and Termination. — As a rule, sarcoma runs a 
much slower course than carcinoma, but its termination is none the less 
fatal. Sarcoma is not only more slow in its original development, but 
it is also less prone to recur rapidly and perniciously than carcinoma. 
Thus a sarcoma of the body may be removed by the curette and caus- 
tics, and apparently cured over and over again, before it finally per- 
forates that organ or by constitutional cachexia proves fatal. This 
latter termination may under appropriate treatment be deferred in 
favorable cases for from five to six years, the average duration of can- 
cer being scarcely two years after it has first been discovered ; still, 
this comparison should be received with some hesitation, since sarcoma 
occasionally terminates fatally with great rapidity, and carcinoma again 
at times runs a very slow and latent course. As in carcinoma, the 
patient gradually sinks under the morbid influences of hemorrhage, 
septicaemia, spread of the disease to neighboring viscera, metastasis to 
distant organs, disturbances of nutrition, or peritonitis. 

Prognosis. — This is, of course, invariably unfavorable unless the 
disease, as indeed is the case with true cancer, is discovered at so early 
a stage that the w T hole of the diseased tissue, even though it may 
involve the entire uterus, can be safely and completely removed. The 



TREATMENT. 561 

harder the tissue of the neoplasm, the more slowly it grows ; the softer 
— that is, the more infiltrated with cellular elements — the more rapidly 
it increases, and therefore the less favorable the prognosis. 

Treatment. — As soon as the diagnosis has been made the treatment 
consists, in as thorough a removal as possible of the diseased tissues 
down to the underlying or adjacent healthy structures. 

In the case of the cervix this may be effected with the knife, scis- 
sors, galvano-cautery wire, Paquelin's thermo-cautery, or strong caus- 
tics, preferably chloride of zinc, and in favorable cases of this location 
of the disease a complete cure is undoubtedly possible. When the dis- 
ease is situated in the uterine cavity, the palliative treatment consists 
in scraping away the sarcomatous tissues with the sharp curette, and 
applying either the chloride of zinc in a 50 per cent, solution, or the 
persulphate of iron equal parts with glycerin, or a strong tincture of 
iodine ; but, as indicated, such treatment is merely palliative, and care 
should be taken that in endeavoring to relieve the patient of her hem- 
orrhages and the profuse wasting discharge perforation of the uterine 
wall by the curette or the caustics is not accidentally produced. Spie- 
gelberg reports two such perforations with the curette, and Sims and 
others mention a similar accident as the result of caustics applied to 
the uterine cavity. The only radical means of cure of sarcoma of the 
body of the uterus is the complete extirpation of the diseased organ. 
Attempts have been made to effect this purpose by removing the supra- 
vaginal portion of the uterus through an abdominal section, and some 
successful results have been thus achieved ; but unquestionably the 
ideal indication for the operation of the complete removal of the uterus 
by means of the vaginal method is given by precisely these cases of 
sarcoma and carcinoma limited to the body of the uterus. If under- 
taken sufficiently early before any possibility exists that the para-ute- 
rine tissues are involved, a complete and permanent cure must certainly 
result. 

Sarcoma of the Pelvic Cellular Tissue. — While not coming 
under this precise heading, we have thought it worth while to include 
under Sarcoma the mention of a sarcomatous degeneration of the cell- 
ular tissue of the pelvis of which we have seen several instances. A 
large tumor presented itself to us in two cases, situated behind the cer- 
vix and pushing the uterus forward, which simulated a pelvic hematoma 
or an effusion of some kind into the pelvic cellular tissue. The cachec- 
tic appearance of the patients led us to suspect something more serious 
than a mere effusion of blood. On opening the tumors per vaginam 
we evacuated a large quantity of broken-down coagula intermixed with 
flesh-like masses, and on introducing the finger we found a large cav- 
ity, the walls of which were studded with friable, easily-bleeding excres- 
cences which could be readily removed by the finger and a Sims 
depressor used as a curette. Under the microscope these masses pre- 
sented the unquestionable appearances of round-celled sarcoma. The 
extra-peritoneal location of these cavities could not be doubted. Both 
patients succumbed to the usual symptoms indicative of malignant dis- 
ease, and the post-mortems verified the diagnosis. 



562 CANCER OF THE VTERUS. 



CHAPTER XXXIX. 

CANCER OF THE UTERUS. 

Definition. — Between cancer of the uterus and the same affection in 
other parts of the system there are no marked differences. As in other 
organs, it may be defined as a disease which is characterized by great 
proliferation of connective tissue, excessive generation of cells of epi- 
thelial type, and marked tendency to extension to neighboring parts, to 
molecular death, and to return after removal. Waldeyer 1 concisely 
defines cancer as "an atypical epithelial neoplasm." 

History. — Becquerel asserts that, " in spite of its great frequency, 
cancer of the uterus is not a disease of which the history has been long 
known." That it was not understood as we understand it to-day is 
most true, but the ancients surely had a certain degree of knowledge 
concerning its clinical features. Hippocrates — Be Morbis Mulierum 
— describes it at length, declaring it to be incurable. Archigenes 
wrote a chapter upon it, describing the ulcerated and non-ulcerated 
forms and the peculiarities of the discharges. His article is preserved 
by Aetius, who entitles it " De Cancris Uteri," and is copied verbatim 
by Paul of iEgina without the slightest acknowledgment. The Ara- 
bians likewise were familiar with it, Alsaharavius, Haly Abbas, and 
Rhazes all alluding to its prognosis and treatment in a manner which 
leads us to believe that they understood its true nature. 

Upon the revival of gynecology in France the disease was confounded 
with fibrous tumors and areolar hyperplasia. Astruc described "scir- 
rhus " in 1766 as the result of abortion, and the confusion which 
attached to his description extended long after him. It characterized 
the times of Recamier and Lisfranc, and even so late as our own period 
we see the vieAv endorsed by Ashwell, Montgomery, Duparcque, and 
many others. Blatin and Nivet, 2 in expressing their belief that scir- 
rhus results from chronic inflammation of the parenchyma, append 
the following footnote : " Paul of iEgina, Galen, Andral, Broussais, 
Breschet and Ferrus, Piorry, Bouillaud, etc. place scirrhus among the 
terminations of chronic inflammation ; some of them, however, admit 
the existence of a predisposition." 

While the physicians of ancient times show that they knew of the 
existence of this disease, they have done very little to aid us in under- 
standing its true nature. Within quite recent years this uncertainty 
has been increased by the addition of certain confusing terms which 
only deferred the understanding of the true character of cancer, and 
led to mystifications which at the present day, under the influence of 
recent microscopical investigations, seem entirely inexcusable. Thus 
we find in books of not very remote date descriptions of an affection 
called "rodent ulcer" or "cancroid" or " cockscomb granulations " 

1 Billroth, Surg. Pathol, Am. ed. 2 Mai. cles Femmes, Paris, 1842. 



PATHOLOGY. 563 

(John Clark, Sir Charles Mansfield Clark, Ashwell, Churchill), which, 
to our present understanding indicate with absolute clearness true can- 
cer of the epitheliomatous variety. Such descriptions were of course 
limited to the cervix uteri. The " rodent ulcer," the "cancroid," the 
"lupus," the "malignant ulcer" described by these and other author- 
ities were nothing but epithelioma of the cervix. It is to a correct 
understanding of the microscopical elements of the tissues involved 
and of the clinical course of these affections that we now owe the pos- 
sibility of an easy diagnosis of these cases? Even the rare forms of 
hard cancer of the cervix known as scirrhus, which formerly were 
looked upon as merely a hyperplasia or sclerosis of that part, are now 
recognizable by our improved methods of examination. 

Pathology. — Although in former years, and perhaps in some quar- 
ters still at the present day, there may be a difference of opinion as to 
whether cancer of a single organ is the result of, a pathological change 
in that organ or of a peculiar constitutional taint which manifests itself 
locally, the general opinion at present is that cancer is a local disease, 
beginning in the organ where it first shows itself, and then either 
remaining local and terminating fatally through its communication to 
neighboring organs or through a contamination of the whole system. 
This means that if discovered at a sufficiently early stage cancer may 
be entirely cured by removal of all diseased tissue. Manifestly, if the 
original and primary cause of the cancer consisted of a constitutional 
taint, the local extirpation of the diseased parts would not cure the dis- 
ease permanently. But the result of numerous operations proves that 
the proposition first laid down is the true one, and we confidently 
believe that so long as the tissues surrounding the diseased part are not 
involved macroscopically or microscopically in the morbid process, a 
complete extirpation of the cancerous mass will unquestionably effect a 
permanent cure. We are therefore firm believers in the local origin 
and nature of this disease so long as it remains confined to the organ 
originally affected. The question of constitutional predisposition is as 
yet sub judice, and we do not pretend to deliver a positive opinion on 
that point. In all probability, basing upon researches by Waldeyer, 
Thiersch, Koester, Billroth, Klob, and others, cancer originally begins 
in the epithelial linings of the lymphatic glands, and thence spreads 
more or less insidiously to the neighboring parts. 

If the cervix uteri has been first affected, the disease spreads from 
this point, invades the whole neck and sometimes the body of the ute- 
rus, the ovaries, vagina, bladder, and intermediate tissue. Even the 
bones of the pelvis may be attacked. For a varying length of time 
the deposition goes on ; then without assignable cause the lowly-organ- 
ized mass begins to die and ulceration or molecular death occurs. The 
detritus gives rise to a fetid, ichorous, and bloody discharge, which 
excoriates the vulva and thighs, and renders the patient disagreeable 
to herself and all around her. 

The disease extends to neighboring and distant organs by several 
methods : first, by continuous growth ; second, by absorption of con- 
tagious fluid or cell-elements from the cancer by the lymphatics and trans- 
mission to the glands and other parts; and third, by venous absorption. 



5G4 



CANCER OF THE UTERUS. 



Varieties. 1 — Cancer may attack the uterus in any one of the follow- 
ing forms : 

1st. Epithelioma ; superficial or epithelial cancer ; 

2d. Encephaloid or soft cancer ; 

3d. Scirrhus ; fibrous or hard cancer. 
1. Epithelioma, Superficial or Epithelial Cancer. — This 
variety usually affects the lining membrane of the cervical canal and 
the lips and adjacent parts of the vaginal portion of the cervix. It 
consists in an infiltration of the tissue of the cervix with numerous 
epithelial cells arranged in nests or shoots, so called trabecule, together 
with an Irypertrophy of the normal papillae of the cervix. There are 
two varieties — namely, that in which the hypertrophy of the papillae 
predominates, the interstices between the hypertrophiecl papillae being 
occupied by these accumulations of epithelial cells arranged in regular 
clusters and shafts. This peculiar arrangement of epithelial cells enclosed 
in connective tissue is the characteristic of this form of cancer. The 
development of the papillae in this variety may be so great as to form a 
tumor sprouting from one or both of the lips of the cervix and occupy- 
ing the vagina even down to its orifice. The tumor may attain the size 
of a large orange, or even on rare occasions of a foetal head, so as to 
prevent the examining fingers from reaching its attachments to the cer- 
vix. This is the variety known as cauliflower growth (Fig. 272), from 



Fig. 272. 



Fig. 273. 





Proliferating Epithelioma of Cervix 
(cauliflower growth). 



Flat Epithelioma of Cervix. 



its similarity to the head of the well-known vegetable of that name. 
The vaginal walls may become infected by a direct spread of the 
disease or by infection at some point in the lower part of the canal. 

1 Although, to be systematic, we have deemed it best to adopt these conventional 
terms, the student must not imagine that it is always an easy matter to classify a ute- 
rine cancer under one of them. Very commonly a growth will be met with which 
occupies a middle ground between these varieties, and is neither pure scirrhus, ence- 
phaloid, nor yet epithelioma. 



VARIETIES. 



060 



The second variety is likewise characterized by the infiltration of 
the superficial tissues of the cervix with the cellular elements occurring 
in the first variety, but the hypertrophy of the papillae is absent, and 
the disease therefore presents merely an abraded, usually somewhat 
excavated appearance, extending up into the cervical canal, associated 
with more or less enlargement of the intra vaginal portion of the cervix. 
It is this form which was undoubtedly mistaken in previous years for 
rodent ulcer or cancroid. 

This epithelial variety commonly extends up the cervical canal into 
the uterine cavity if the disease has existed for any length of time. 

2. Encephaloid. — This form of cancer of the cervix is character- 
ized by diffuse infiltration of cells — not of the epithelial variety neces- 
sarily, but of round, spindle, and caudate cells, not usually found in 
.these parts, together with a proliferation, but of a lesser degree than the 
cell-development, both of which together produce a decided enlarge- 
ment of the cervix, chiefly of that part of it which is situated above 
the vaginal insertion. There is no vaginal tumor, properly speaking, 
but the normally slender or conoid 
cervix is enlarged in every diam- 
eter, very much like the body of 
a turnip. The parametria are not 
involved in the early stages ; there 
is no open surface, therefore no 
bleeding and no ulceration in this 
form of the disease (Fig. 274). 
The feel of the enlarged cervix to 
the examining finger is more or 
less soft, somewhat nodular or 
irregular in outline. In these 
cases it is often difficult to differ- 
entiate between this disease and 
hyperplasia of the cervix. By 
gradual extension this form of 
cancer may also spread to the 
adjacent parts and to the body 
of the uterus. This is the next 
most common variety of cancer of the cervix. 

3. Scirrhus. — By the increase of the connective and fibrous ele- 
ments of the part it is enlarged very similarly to the condition described 
in the previous form. The difference is that, in contradistinction to the 
encephaloid, the hyperplasia of the fibrous tissue predominates decid- 
edly over that of the cellular elements. The cervix is not only 
enlarged, but very hard, dense, almost cartilaginous, and usually 
extremely nodular to the examining finger. There is no bleeding. 
no eroded portion, and the suspicion of malignant disease rests entirely 
upon the irregular nodular enlargement of the cervix, out of proportion 
to the size of the rest of the uterus. This form of the disease is in 
our experience the slowest of development, the last to break down, pro- 
duce hemorrhage and constitutional symptoms. 

We are aware that this division of the forms of cancer oi' the cervix 



Fig. 274. 






%, 

Sw 


*•> .&.---' 


w 







Encephaloid of Cervix. 



566 CANCER OF THE UTERUS. 

uteri is to a certain extent arbitrary, and that microscopically typical 
and ideal cases of each variety may not always be easy of demonstra- 
tion, since when the disease comes under our observation the forms have 
more or less become merged into each other. The ultimate result clin- 
ically of these three varieties is the breaking down, destruction, and 
sloughing of the diseased part, so that at a certain time in the progress 
of each one of these varieties it is impossible for the examiner to say 
in what way the disease originally started. 

While, therefore, for theoretical and descriptive purposes it is 
necessary and desirable to describe the three forms of cancer of the 
cervix uteri as we have here done, clinically it is often impossible to 
differentiate between them. 

Frequency. — Cancer of the uterus is a very frequent affection, about 
one-fourth of all fatal cases of this disease being those involving that 
organ. Gurlt found in 11,140 women with tumors, 1399 benign and 
5029 doubtful and malignant genital tumors. Of the latter, 3521 were 
uterine tumors, and of these 3449 were carcinoma of the uterus and 
vagina. According to Rokitansky, cancer is found most frequently — 
first, in the uterus ; second, the female breast ; third, the stomach ; 
fourth, the large intestine, especially the rectum ; fifth, the lymphatic 
glands, etc. 

Of all cases of cancer in females, the uterus is affected in f — Kiwisch. 1 
"9118 " " " " was " 2996— Tanchou. 2 

" 8746 " " " " " " 3000— Simpson. 3 

" 5122 " " " " " " 113— Wagner. 4 

Statistics prove that cancer is nearly three times more frequent in 
women than in men, and more than three times more frequently met 
with in the uterus than in any other organ of the female. 

The most frequent variety in our experience is that of epithelioma 
of the cervix, the next encephaloid, and the third scirrhus of the same 
part. 

Etiology. — Nothing positively certain can be said about the causes 
of cancer of the uterus, either predisposing or exciting. 

Predisposing Causes. — Those predisposing causes which are gen- 
erally admitted may be thus enumerated : 
Hereditary tendency ; 
Middle or advanced life ; 

Race, the African enjoying partial immunity ; 
Repeated parturition ; 
General depreciation of vital forces. 
Among the predisposing causes heredity is supposed to play a very 
prominent part, but we confess that we are doubtful as to its real value. 
Some authors state that in proportions varying from 7.6 to 13 per cent, 
hereditary predisposition is present. Winckel mentions about 6.3 per 
cent, of such cases from his own experience, but we do not consider 
these figures to indicate in any degree that cancer of the uterus, any 
more than cancer of any other organ of the body, is positively hered- 

1 Klob, op cit., p. 205. 2 Rech, sur les Tumeurs du Sein, p. 218. 

3 Clin. Led., p. 42. 4 New York Med. Journ., vol. ix. p. 561. 



PREDISPOSING CAUSES. 567 

itary. That the unknown and mysterious taint of cancer may be 
transmitted, like that of tuberculosis, can perhaps not be denied ; but, 
so far as cancer is concerned, statistics do not seem to clearly bear out 
this conclusion. Probably the most plausible predisposing cause of 
cancer of the cervix is a prolonged and frequent irritation of some kind 
of that organ, such as might be produced by a chronic cervical catarrh, 
especially if associated with hyperplasia of the glands of that cavity — a 
cause chiefly existing in virgins and nulliparous women ; further, a 
laceration of the part, together with an eversion, erosion, and papillary 
hyperplasia. Unquestionably, laceration of the cervix, when inducing 
and presenting such a pathological degeneration of the injured organ, 
forms in our experience a certain predisposing factor for malignant 
degeneration. Cancer of the cervix undoubtedly most frequently 
occurs in married women, especially in those who have borne children. 
Winckel states that women w T ith cancer of the womb are very rarely 
entirely sterile, only 1.7 per cent, instead of 20 per cent. Of the mul- 
tiparous women afflicted with cancer, the average number of children 
was 8.2 per cent. An unusual number of abortions and premature 
deliveries is mentioned also by some authors among the possible causes 
of this disease. While, therefore, pregnancy and parturition more or 
less frequently repeated do not show any positive evidence of predis- 
position to cancer of the uterus, difficult, prolonged, and instrumental 
labors, especially such as result in an injury to the cervix, decidedly 
show such a predisposition. Hofmeier found only 4.8 per cent, of 
nulliparae in 812 cases of carcinoma; Funk found 69 sterile women in 
a total of 925 having cancer. According to Schroeder, the proportion 
of hereditary cases is probably 78 : 948, and prostitutes were not espe- 
cially liable to uterine cancer. 

While some authors state that mental anxiety, sorrow, and trouble 
may account for the production of some cases of cancer, and thus for 
the greater frequency of this disease in the poor than in the rich, we 
think it more likely that the prevailing bad nutrition in the poorer 
classes, depending partly upon the necessity for greater physical exer- 
tion and the want of adequate and proper nourishment, is the real rea- 
son for the preponderance of the disease among the poor. Whatever 
the cause of cancer may be, whether it appears in the uterus or else- 
where, it would seem to begin by the formation of certain poorly-devel- 
oped, so-called embryological cell-elements, which gradually increase in 
quantity and size, and when invading the normal tissues of the part 
more or less change their shape and character. [That cancer does 
begin by this peculiar formation of embryological elements seems to 
be proved by a case which I met with in 1884. In October of that 
year I removed the uterus by vaginal hysterectomy for cancer of the 
cervix, which had not extended to the parametrium : hence I was able 
to carry my line of incision well without the range of the diseased tis- 
sue, and apparently entirely in normal structure. The microscopical 
examination of the specimen, made soon after the operation by Dr. 
Charles Heitzmann, showed at a point corresponding to the seat of the 
disease peculiar evidences which induced Dr. Heitzmann to write me 
that at this very point (he not knowing that this was the spot nearest 



568 CANCER OF THE UTERUS. 

the diseased portion of the cervix) there were certain formations of 
poorly-developed ernbryological cells, and that in case the cancer 
returned it would do so in the cicatrix at this very location within a 

Fig. 275. 




1 i *-Ui**SpJ^i^ir& 











Epithelioma, microscopical appearance (Delafield and Trudden). 

period probably not longer than a year. After nine months of entire 
health a small ulceration made its appearance at the very spot indi- 
cated by Dr. Heitzmann, and its rapid development showed its cancer- 
ous nature. — P. F. M. 1 ] 

A curious theory of Cohnheim, which appears not entirely foreign 
to the theory just expressed by Heitzmann, is that cancer of the uterus 
originates in irregularities in embryonic life — an excessive proliferation 
of certain kinds of cells at a very early stage — the only essential to 
this production being a plentiful vascular supply. Gusserow agreed 
with this hypothesis of Cohnheim, while AVinckel and Schroeder have 
opposed it for the reason that it is not proved why, if such germs exist 
in many individuals, they remain dormant in a large proportion and 
develop into malignant growths in others. 

Exciting Causes. — In persons in whom the predisposing causes 
already mentioned are present it seems not improbable that an active 
stimulant or irritant applied to a favorable part of the body will incite 
a rapid production of cells and papillae with the peculiar characteristics 
of carcinoma : hence a blow or any other certain traumatism, such as 
active, frequently-repeated, and impetuous coition, the application of 
caustics to the part, might possibly be the direct exciting cause of car- 
cinoma of the cervix. Of course this assumption does not account for 
the development of cancer in the body of the uterus ; the organ to 
which it perhaps applies most forcibly after the uterus is the female 
breast, which is more frequently subjected to accidental or intentional 

1 See American Gynecological Transactions, 1884. 



AGE. 



569 



violence than any other external gland of the body. Of course this 
supposition is merely a theory and cannot be proved by any reliable 
statistics. 

Age. — The most favorable age is between forty and fifty years, but 




Encepbaloid Carcinoma, microscopical appearance. 



J.W&t 



cancer of the uterus has been observed in children and in women far 
beyond the menopause. Zweifel removed a uterus through the vagina 
for epithelioma of the cervix in a girl of thirteen. We (P. F. M.) 
saw such a case in a girl of eighteen, and another of epithelioma of 
the posterior vaginal wall in a girl of twenty. 

The following table contains the results of a collation of 3385 cases 
prepared by Gusserow 1 from the writings of Lever, Kiwisch, Chiari, 

1 Die Neubildunqen des Uterus, Stuttgart, 1885. 



570 



CANCER OF THE UTERUS. 



Fig. 277. 




LiV&. 



Scirrhous Carcinoma, microscopical appearance. 



Scanzoni, Saxinger, Tanner, Hough, Blau, Dietrich, Lothar Meyer, 
Lebert, Glatter, Beigel, Schroeder, Schatz, Winckel, and Champneys : 



17 


pears, 


1 case (Glatter). 


19 


u 


1 " (Beigel). 


22-30 


" 


114 cases. 


30-40 


" 


770 " 


40-50 


" 


1169 " 


50-60 


u 


856 " 


60-70 


" 


340 " 


Above 70 


u 


193 " 



Schroeder has published the results of his hospital and private prac- 
tice, as follows : 

Of 14,000 consultations in the hospital, 285 (1.9 per cent.) were for myoma. 

Of 16,800 consultations in the hospital, 603 (3.6 per cent.) were for cancer. 

r\r n/inn u A - • i • • * *• [557 (5.7 percent.) were for mvoma : 

Of 9400 consultations in his private practice, < OAn )„ , F .{ ? - ' 

F r ' \ 209 (2.1 per cent.) were for cancer. 



SYMPTOMS— PHYSICAL SIGNS. 571 

These figures will prove that myoma is more common in the better 
classes, and cancer among the poor, thus agreeing with the general 
opinion on this subject. 

Race seems to have something to do with the production of cancer ; 
at least there seems to be less predisposition to this disease in the negro 
races than in the white — a proportion which is entirely reversed in the 
case of uterine fibroids, which are far more common among negroes. 
According to Chisholm, only 1 of '300 negroes of both sexes had can- 
cer, against 1 out of 100 in the white races. 

Symptoms. — The disease may pass through its period of inception 
and make considerable progress toward a fatal issue without developing 
any symptoms which attract the attention of the patient. Or only 
slight leucorrhoea and hemorrhage may exist, which may have been 
passed over as trivial circumstances not deserving investigation or treat- 
ment. Usually the following symptoms develop themselves and become 
more and more prominent as molecular death advances : 

Pain through the pelvis; 

Tenderness upon movement or coition ; 

Menorrhagia and metrorrhagia ; 

Ichorous and fetid leucorrhoea ; 

Hydrorrhcea ; 

Dark, grumous discharge ; 

Constitutional debility ; 

Pallor and cachectic fades ; 

Vesico-vaginal or recto-vaginal fistulse. 
Pain and tenderness are not nearly so constant or severe as is often 
supposed, and they may both be entirely absent. 

Menorrhagia and metrorrhagia may exist even before ulceration has 
occurred, resulting then from congestion of the mucous membrane. 
But it is not until after the inauguration of the process of destruction 
that they become alarming or excessive. 

Ichorous, watery, and grumous discharges very generally mark the 
advance of the disease. The first of these discharges produces ery- 
thema, erosions, vaginitis, and sometimes 1 a strong sexual appetite. 
The second exhausts the patient by draughts made upon the serum of 
the blood. The third creates fetor, and sometimes results in septi- 
caemia, for the material giving color and odor to the flow is a putrilage 
formed by the detritus from the decaying uterus. 

Constitutional debility and cachectic facies are the results, in part, 
of the malignant toxaemia which is the basis of the disorder, in part of 
exhaustion produced by loss of blood or some of its elements. Should 
the walls of the rectum and bladder become implicated, as they very 
often do, the functions of these viscera are deranged, and the feces or 
urine, or both, pour out through the vagina, increasing the misery of 
the patient. 

Physical Signs. — Suspicion is generally first aroused and physical 
exploration prompted by these three symptoms: monorrhagia, fetid 
discharge, and ichorous leucorrhoea. They belong to the second or 
ulcerative stage of the affection, and it is almost invariably in this 

1 We have never met with this symptom. 



572 CANCER OF THE UTERUS. 

stage that the physician is consulted. Before the occurrence of this 
stage no symptom usually exists which calls for physical exploration. 

[As I have already stated, I have seen but two cases which I am 
positive were incipient or non-ulcerated scirrhous cancer. In these the 
diagnosis was made by the peculiarly hard, nodular sensation yielded 
by the cervix, and in one by the coincident implication of the vagina. 
— T. G. T.] We feel sure, however, that he who ventures upon a 
decision as to the nature of the disease at this stage must expose him- 
self to great risk of error. The mere fact of the cervix being excess- 
ively hard and nodular is not enough to warrant a diagnosis. This 
must be accompanied by other reliable signs, as menorrhagia, hydror- 
rhoea, and constitutional failure, to make a positive conclusion admis- 
sible. 

For this period of the disease — a period at which diagnosis is of 
extreme importance in view of the fact that then ablation offers the 
greatest hope for permanent or temporary relief — Spiegelberg offers a 
valuable resource in the use of sponge tents. If the induration of the 
tissue be benign, the dilating influence of the tent will produce a 
degree of softening, while if it be due to malignant disease the tissue 
will remain unyielding and hard. 

After ulceration has occurred diagnosis, to an experienced examiner, 
is as simple and certain as it is obscure and uncertain before it. The 
finger discovers an absolute destruction of tissue, and finds the walls 
of the deep and ragged ulcer producing it covered over with a crum- 
bling, brittle mass, interference with which causes hemorrhage. The 
uterus is often fixed by secondary inflammation or diffuse deposit of 
cancerous matter, and the walls of the vagina near the uterine junction 
participate in the deposit. Sometimes there is a stricture of the rec- 
tum, which especially engages the attention of the patient, who suspects 
no disease of the uterus or vagina. 

It is difficult to describe to another the peculiar sensation yielded 
by an ulcerating cancer, but it is easy to appreciate it by touch. He 
who carefully explores one case, and notes the hard, unyielding border 
and brittle surface, with its marked tendency to crumble and produce 
hemorrhage, will rarely fail to recognize another. 

Nevertheless, it is in all cases safe, and in some essential, to remove 
a small portion of the cancerous material, if it can be done without 
creating great flow of blood, for examination with the microscope. 
And now arises the question, What are the microscopic tests of cancer ? 
This subject is one which we cannot leave unnoticed, and yet one with 
which we must deal as cursorily as is consistent with a concise state- 
ment of the existing views of pathologists upon it. This can, we 
think, most readily be done by a series of propositions : 

1st. There is no typical cancer-cell which, separated from its sur- 
roundings and viewed as an entity, enables a microscopist to pronounce 
upon a growth. 

2d. There are certain combinations of cells, alveoli, and stroma 
which do enable a microscopist to pronounce an opinion as to the 
benignity or malignancy of a growth. 

3d. This combination consists, in general terms, in the existence of 



DIAGNOSIS AND DIFFERENTIATION 573 

a fibrous stroma containing ovoid alveolar spaces, filled with masses of 
cells with large single or multiple nuclei, and all bearing more or less 
closely a resemblance to epithelium. 

Diagnosis and Differentiation. — As a rule, no one who has had the 
opportunity to examine a fair number of cases of cancer of the cervix 
would hesitate for a moment in making the diagnosis of a well-marked 
case of that kind by a simple examination with his finger. In the early 
stage of the disease, before ulceration and destruction of tissue have 
taken place, the salient points of diagnosis of the three varieties are 
the following : 

Epithelioma — Papillomatous Variety. — The vagina is more or 
less occupied by a soft, cauliflower-like or sponge-like mass which 
bleeds freely on touch, from which a sero-sanguineous non-odorous fluid 
exudes, and which appears to spring from one or both lips of the cervix. 
This mass may be so large as to completely fill the vagina and prevent 
the examining finger from reaching its point of origin in the cervix. 
The mass can w T ith very slight force be broken down by the examining 
finger ; there is usually very little pain attending such an examination. 
The body of the uterus, if it can be felt bimanually, is movable, and 
the vaginal vault and parametrium are not involved. If the epithe- 
lioma springs only from one lip, the external os may be detected and 
its position verified by the introduction of the sound into the uterine 
cavity. 

Flat or Ulcerating Variety. — This appears as a more or less 
excavated, freely-bleeding ulceration of the cervix, involving both the 
vaginal portion of that organ and more or less of the cervical cavity. 
The vagina and parametrium are usually free and the uterus is mov- 
able. 

Encbphaloid Variety. — The cervix presents a swollen, irregularly 
nodular feel, is enlarged to twice or more its normal size, most of the 
enlargement being supravaginal and extending toward the parametria. 
The body of the uterus appears free. The external os is more or less 
gaping, and usually free bleeding is excited by an attempt to pass the 
finger into the cervical canal. The feel of the enlarged cervix is rather 
soft, and considerable pain is experienced on firm touch. 

Scirrhous Variety. — The cervix is enlarged to double or more its 
size, nodular, very hard, almost like cartilage, and the induration may 
extend up into the supravaginal portion. There is no bleeding on 
examination, and the external os is usually small and its lips rigid. 
The feel of the cervix is so much harder than that of mere hyperplasia 
of the organ that an experienced finger very readily suspects the true 
diagnosis. In the first two varieties the microscopical examination is 
scarcely ever needed to verify the diagnosis. In the scirrhous form, 
however, at this stage the microscope may be needed to settle the 
diagnosis. 

In the later stages, after the three varieties of the disease have 
become more or less merged into each other by increase of cellular ele- 
ments, and when a destruction of the diseased part has taken place 
with an actual loss of substance, the diagnosis is even more easy, and 
no difference can be detected between the" three varieties. In place of 



574 CANCER OF THE UTERUS. 

the cauliflower growth, of the flat bleeding ulcer, of the soft hyper- 
trophied supravaginal portion of the cervix, of the hard cartilaginous 
cervix, there is now a more or less extensive crater-shaped excavation 
extending from the vaginal vault up toward the uterine cavity. The 
intra-vaginal portion of the cervix has in fact entirely disappeared, 
leaving only an irregular, freely-bleeding, and secreting cavity. The 
discharge is now not only bloody, but usually exceedingly offensive, 
having the odor of putrefying and decomposing flesh. The parametria 
have become involved ; there may be a distinct tumor or thickening 
in the para-uterine tissues. The mobility of the uterus is limited or 
entirely absent. The vagina may also participate in the degeneration. 
For a diagnosis of cancer of the cervix the finger usually suffices ; 
in some cases it is necessary to verify the appearance of the part by the 
speculum ; but he who begins by making a diagnosis of this disease 
through the speculum shows that he is not conversant with its physical 
signs. After these remarks it would seem that on theoretical grounds 
the diagnosis of cancer of the cervix is so simple that few errors would 
occur in reference to it. This, indeed, ought to be the case, and is 
really so with all skilful diagnosticians, but still curious errors are 
occasionally made by the inexperienced, and even those who are well 
versed may at times be led astray. The conditions with which cancer 
of the uterus may possibly be confounded are : 

Eversion of cervix from laceration ; 

Papillary hypertrophy of the cervix (" cock'scomb ulcer"); 

Sloughing fibrous polypus ; 

Uterine fibroids ; 

Syphilitic ulcer ; 

Areolar hyperplasia of cervix with metrorrhagia ; 

Sarcoma of the uterus ; 

Retention of products of conception. 
From these a differentiation should be arrived at by careful study 
of the progress of the case, by the degree of constitutional implication, 
by the results of microscopic examination, and by the development of 
a tendency to return after removal. A positive conclusion is not always 
easy, or, without delay, even practicable. An intelligent decision of 
the question must depend upon care in investigation, thoroughness of 
examination, and upon time, which in most cases will clear up all doubt. 
It should be remembered that the diagnostician, however skilful he may 
be, w T ho bases an opinion upon the sensation of hardness and resistance 
in the cervix is running a great risk of error. Let it be borne in mind, 
too, that syphilitic ulcers have been known to eat into the bladder and 
rectum, and create very much such a state of things in the vagina as 
carcinoma develops. 

Prognosis, Duration, and Course. — The prognosis is pre-eminently 
unfavorable. Not only is it so from the fact that the disorder is can- 
cerous, but because that form which often affects the uterus belongs to 
the most rapid and dangerous of its varieties. 

In some cases death will ensue in from three to six months, while 
in others it may not occur for five, six, or seven years. The prognosis 
should be governed in great degree by the character of the initial affec- 



PROGNOSIS, DURATION, AND COURSE. 575 

tion: true carcinoma, which begins with profound implication of sub- 
jacent parenchyma, runs a more rapid course than epithelioma, which 
often involves only superficial portions of it. The general experience 
as to the duration of cancer of the uterus may be inferred from the fol- 
lowing citation of authorities : 

Simpson gives as an average 2 to 1\ years. 

Lebert " " about 16 months. 

West " " about 15 months. 

Barker " " 3 years and 8 months. 

Gusserow " " 12 months. 

Lever " " 20 months. 

Seifert gives an average for medullary carcinoma of eighteen months ; 
of epithelial, thirty-six months. Winckel reports that the longest dura- 
tion observed by him in a recurrent papillary cancroid was three years 
and eight months. A. Martin records the shortest duration observed by 
him as nine weeks ; the longest, with repeated operations, as five years. 
Of course the time from which the duration of the disease is dated in 
these statistics does not mean the actual inception of the morbid pro- 
cess, which must have begun at least some months before the patients 
came under observation. 

The termination of cancer of the uterus, if the disease be uninter- 
fered with, is very generally a fatal one, although it is admitted that 
there is a possibility that the mass may slough away, the surface heal 
over, and the patient recover. Scanzoni, Rokitansky, Kiwisch, Vir- 
chow, and Klob, all announce this fact, strange though it may appear 
to one who has always taken a more gloomy view. "The cases of 
spontaneous recovery from uterine cancer," says Rokitansky, 1 "are of 
extreme rarity, but they do occur." " In opposition to the above phe- 
nomena, which inevitably lead to death," says Klob, 2 "the universally 
acknowledged possibility of spontaneous recovery from uterine cancer 
is interesting." 

Under these circumstances the whole vaginal portion of the cervix 
usually sloughs off and the os internum becomes the os externum. 
Instances of spontaneous recovery from true carcinoma are reported 
by Barker, Habit, and Mettauer, where the sloughing of the uterus 
followed the application of the acid nitrate of mercury, and the patients 
remained entirely well. Kiwisch also relates a case of gangrenous 
sequestration of the entire cancerous uterus. [I have reported a sim- 
ilar case in the American Journal of Obstetrics for Aug., 1872, where, 
after curetting and the application of a solution of perchloride of iron. 
a peritonitis set in, and all that was left of the uterus sloughed out. 
The patient was under the care of the late Dr. Alfred Wiltshire of 
London, at whose request I operated on her, and from whom I heard 
subsequently that the disease returned in the cicatrix about two 
months later. — P. F. M.] The cases of Barker, Mettauer, Habit, and 
Munde are, so far we know, the only ones reported in which the entire 
cancerous uterus sloughed away. 

When death, which is the almost inevitable issue of cancer, does 
occur, it is usually due to hemorrhage, septicaemia, uraemia, marasmus, 

1 Op. c//., vol. ii. p. 22S. •' Op. eft., p. 203. 

37 



576 CANCER OF THE UTERUS. 

or some one or more of the numerous complications which we now come 
to enumerate. 

Complications. — The following are the complications which occasion- 
ally accompany the disease : 

Septicaemia from absorption of putrid fluid ; 

Cellulitis ; 

Hydronephrosis ; 

Peritonitis ; 

Phlebitis ; 

Embolism ; 

Cancer in lymphatic glands or other organs. 
In rare cases cancerous degeneration obstructs the ureters and pro- 
duces in this way uraemic poisoning. The most frequent cause of death, 
in our experience, is marasmus or the gradual wasting away produced 
either by the repeated hemorrhages, the exhausting serous discharges, 
or, if these are checked, by the septic and toxic influence of the disease 
on the nutrition of the body. 

The tendency of the newly-formed cells of cancer is to rapid death. 
The more prolific and abundant, therefore, the cell-development of the 
neoplasm, the more speedy will probably be its self-destruction and 
decay. In consequence of this rule the epitheliom'atous and encepha- 
loid varieties are the most rapid to break down and slough away ; the 
scirrhous remains unchanged the longest, and usually does not undergo 
gangrene until it has changed from its hard fibrous to the soft cellular 
character. Death usually takes place most rapidly, therefore, in the 
two first-mentioned varieties. 

The disease does not remain limited to the tissues of the uterus alone, 
but very rapidly spreads after a certain time — that is, when it has once 
begun to invade the neighboring organs — to the vagina, bladder, rec- 
tum, pelvic cellular tissue, and even the peritoneum, ovaries, and tubes. 
In very virulent cases the lymphatics and veins surrounding the cervix 
are involved at a period when the examining finger fails to detect any 
pathological changes in them, and hence the possibility of an entire 
removal of the diseased tissues is really never perfectW assured. Com- 
pression of the ureters by the cancerous deposits may, in addition to 
hydronephrosis, cause inflammation of the ureters and of the lining 
membrane of the kidney, and gradually induce destruction of that 
organ or its fatty degeneration — that is, Bright's disease. (Edema 
of the labia and lower extremities in consequence of the pressure 
exerted by the malignant deposit on the pelvic veins is a not infre- 
quent symptom in the later stages. 

Metastasis of the cancerous deposit to other distant organs of the 
body is fortunately not common with cancer of the uterus, the occur- 
rence of cancer in other not adjacent organs being either the result of 
a gradual spreading of the disease or else independent. Patients with 
cancer of the uterus not infrequently succumb to sudden attacks of 
peritonitis (25 per cent.), from a perforation into the peritoneal cavity, 
or from putrid discharge through the tubes. Uraemia is also reported 
to be the cause of the fatal termination in about 45 per cent. As already 



CANCER OF THE BODY OF THE UTERUS. 577 

remarked, gradual exhaustion is the most common cause of death ; life 
being often prolonged, however, by the arrest of retrograde tissue- 
changes induced by the large consumption of opium which we feel it 
our duty to give to these patients in sufficient amount to allay their 
sufferings. 

Part of Uterus affected. — Cancer much more frequently affects the 
neck than the body of the uterus, although some authors, with whom 
we decidedly agree, look upon cancer of the body as much more com- 
mon than is generally thought. 

Cancer of the Body of the Uterus. — Although cancer developed 
in the body of the uterus has attracted very little attention, it is by no 
means exceedingly rare. Among the most recent statistics on this sub- 
ject are those of Schroeder, who found 28 cases of cancer of the body 
among 812 cases of cancer of the uterus, and Schatz saw 2 among 80 
cases. 

The most marked feature of the affection thus making its appear- 
ance is the obscurity which attends diagnosis. For a long time, and 
perhaps throughout the case, uterine hemorrhage and fetid discharges 
will be the only symptoms which will excite suspicion. These leading 
to further and fuller exploration, a portion of the morbid tissue will be 
removed by the curette, examined by the microscope, and thus the 
diagnosis will be established. 

Scirrhus, which is so rare as to be denied by some even in the neck, 
never affects the body, and so rarely does encephaloid do so that some 
pathologists declare that no unquestionable case is on record. The 
supposed cases are, according to them, really instances of sarcoma, 
tuberculosis, or sloughing fibroid growths. When malignant disease 
does originate in the cavity, it assumes the form of epithelioma. 

Peculiar Features of Cancer of the Body. — The symptoms which 
mark the condition are — 

Hemorrhage, especially if occurring after the menopause ; 

Depreciation of vital forces ; 

Cachectic appearance ; 

Fetid discharge ; 

Pains of severe and lancinating character. 
These symptoms having led to examination of the uterus, the follow- 
ing physical signs will probably be recognized: 

Enlargement and hardening of uterine body noticed by biman- 
ual palpation ; 

Increased capacity of uterus ascertained by the probe ; 

Profuse hemorrhage upon probing ; 

Recognition of peculiar intra-uterine growth by introduction of 
finger ; 

Microscopic evidences of cancer. 
Differentiation of Cancer of the Body. — When the rational and phys- 
ical signs here enumerated are carefully developed and considered, a very 
probable diagnosis may be arrived at. Nevertheless, errors of diagnosis 
are common in reference to this disease at the hands o\' practitioners 
who are not familiar with the subject, or who rely too firmly upon one 
or two of these signs or symptoms. We have seen each one oi' the fol- 



578 CANCER OF THE UTERUS. 

lowing conditions mistaken for cancer of the body, and some of them 
we have known to have repeatedly caused erroneous diagnosis : 

A sloughing fibroid ; 

A retained placenta ; 

A sponge left by accident in utero ; 

Syphilitic disease of pelvic bones ; 

Cystic degeneration of chorion (hydatids) ; 

Fibroid tumors or polypi ; 

E-ntero-uterine fistula ; 

Intra-uterine vegetations. 
We do not deem it necessary to go into detail upon the means neces- 
sary for accomplishing the differentiation of these affections from malig- 
nant disease. It will suffice to say that in cases in which doubt exists 
after careful investigation by all the other means here recommended, 
removal of a small portion of a mass and its examination by the micro- 
cope will prove of the greatest assistance, and will probably decide the 
question. 

The not infrequent occurrence of sarcoma of the body of the 
uterus, which, as already described, is practically quite as malignant as 
true carcinoma, should not be forgotten in deciding as to the nature of 
a presumed malignant growth of that organ. In order to remove a 
portion of the intra-uterine growth sufficient for microscopical examina- 
tion, the curette, either blunt or sharp, will usually suffice. Only a 
small portion is needed for the purpose, and no serious damage need 
ever be done in this manner. 

Treatment. 

The indications for treatment are these : 

To amputate or destroy the diseased part as completely as pos- 
sible ; 

To check hemorrhage ; 

To relieve pain ; 

To secure perfect cleanliness and correction of fetor ; 

To sustain the general strength. 
Review the complications of uterine cancer, and it will be seen that 
many of them are of a most fatal character, and at the same time 
entirely beyond the resources of art. A certain number, however, 
which would prove fatal if not avoided or checked, are temporarily 
under the control of the physician. Examples of these are septicaemia, 
hemorrhage, exhaustion from pain, ichorous leucorrhoea, hydrorrhea, 
excessive constitutional debility from the depraved blood-state, and 
last, though not least, the extreme mental depression which is the con- 
sequence of bereaving the unfortunate sufferer of all hope. 

No single plan fulfils so many of the indications for alleviating these 
as removal or destruction of the growth, but no practice in reference to 
this disease can be so pernicious as that based upon the idea that 
because there is cancer of the uterus some surgical procedure must be 
resorted to. The same reasoning which applies to malignant diseases in 
other parts of the body should do so here. If the operator be con- 
vinced that decided benefit is to accrue to the patient from surgical 



TREATMENT. 579 

interference, it should be practised, not otherwise. Should the disease 
be detected early, and sufficient grounds be discovered for a positive 
diagnosis, the propriety of complete removal of the cervix by amputa- 
tion cannot be questioned. 

In the great majority of cases patients suffering from uterine cancer 
are seen so late that surgical interference, established with a view to 
cure, necessarily fails to effect it, although, practised for relief of certain 
symptoms, and thus for a prolongation of life, it is frequently of a great 
deal of benefit. Should amputation of the neck promise entire removal 
of the morbid tissue, it should at once be accomplished, for by it cure 
may be effected. Even where complete removal is not practicable, abla- 
tion of all the superficial portions of the growth tends greatly to the 
amelioration of symptoms. 

There are several surgical procedures by which removal of the 
diseased structure may be effected. One of these will be most appli- 
cable to one case, one to another, that being always selected which in 
the particular case will accomplish the end with the greatest thorough- 
ness. Let it always be borne in mind that the hope of prolonged free- 
dom from relapse depends upon thoroughness of ablation, and upon that 
alone. 

According to the conditions existing in each case, the treatment 
of cancer of the uterus should be either radical or palliative. By 
"radical" is meant the removal of the whole of the diseased tissue, 
with at least a fair prospect of permanent cure. By "palliative" we 
mean that the disease has already so far advanced that its radical cure 
is impossible, and that nothing but a mere relief of symptoms can be 
effected. 

Radical Treatment. — There are two main varieties of radical treat- 
ment for cancer of- the uterus. If the disease is confined solely to the 
cervix, we may employ two forms of radical cure — namely, first, the 
excision of the cervix only ; or, second, the removal of the whole 
uterus. If the disease is limited to the body of the uterus, or if the 
body of the uterus is involved together with the cervix, only the 
removal of the whole organ will effect a cure. 

Removal of the Whole Cervix: Indications. — When a careful 
vaginal and bimanual examination, supplemented by ocular inspection 
through the speculum, proves conclusively that the cancerous infiltra- 
tion is limited to the tissue of the cervix alone, does not spread upward 
above the internal os or laterally into the pelvic cellular tissue or to the 
vagina, then an entire cure may be effected by completely removing the 
diseased tissues and leaving the rest of the uterus undisturbed. It is 
but fair to say that the exact limit of the spread of the disease either 
upward or laterally is not always easy to determine, since, as we have 
already remarked, even the most practised examining finger may fail to 
detect the microscopical spreading of the cancer-elements into the para- 
metrium, and the eye is not able to appreciate the extension of the 
disease toward the uterine cavity; hence the majority of operators, 
especially the Germans, nowadays prefer to remove the whole uterus. 
even though the cervix only is apparently diseased: still, excellent 
results from removal of the cervix alone are reported by Carl Braun 



580 



CANCER OF THE UTERUS. 



Fig. 2 



of Vienna, by Schroeder of Berlin, by Baker of Boston, and by Reamy 
of Cincinnati. 

Methods. — There are three chief methods for performing this ope- 
ration : 

a. Excision. — This is the method of Schroeder and of Verneuil. 
After drawing down the cervix with a vulsellum forceps, two lateral 
silk or wire ligatures are passed deep into the vaginal cul-de-sac for the 
purpose of securing the uterine arteries. These are tied or twisted, and 
then an incision is made transversely through the anterior vaginal Avail, 

the bladder pushed up with the 
fingers or scalpel handle until the 
level of the internal os is reached. 
A similar incision is made behind 
and the peritoneum pushed up in 
the same manner. The two in- 
cisions are then joined, and the 
cervix is excised in a wedge- 
shaped manner with the knife or 
scissors. There is danger of wound- 
ing the peritoneum during this 
operation, and if this is done the 
opening should be at once closed 
by catgut sutures ; bleeding ves- 
sels are at once tied with catgut. 
Deep sutures are now passed 
through the vaginal and cervical 
walls on each side, and tied so as 
to compress all bleeding surfaces 
and cover the stump with vaginal 
mucous membrane. Union by first 
intention may thus be. secured. 
According to Hofmeier, who published Schroeder's results and those 
of some of his assistants during the five years between 1879 and 1884, 
out of 105 partial excisions of this kind only 10 died, and the remote 
results as regards non-recurrence of the disease were excellent. Accord- 
ing to the latest figures, there was 47 per cent, of permanent recoveries. 
Baker practises substantially the same operation, with the quite import- 
ant modification, however, of not suturing the wounded surfaces, but 
instead cauterizing them very deeply with the Paquelin thermo-cautery 
heated to a black heat. In the American Journal of Obstetrics for 
1888 he reported 57 high amputations after this method, with only 2 
deaths. Of 29 cases during a period varying from one to fourteen 
years, a return of the disease was observed ; the 26 others operated 
during a term of one to fifteen years remained in perfect health. 

The method of Verneuil, as described by Pozzi in his recent work, 
is similar to that of Schroeder so far as the extent of the part removed 
is concerned, but instead of using the knife or scissors he uses the 
ecraseur — an instrument which we have long since discarded in all 
operations where it was desirable to know exactly how much tissue 
would be removed without accidentally drawing parts into the bite of 




Wedge-shaped Excision of Cervix. 



TREA TMENT. 



581 



the chain which it was desirable to omit ; hence we infinitely prefer 
sharp cutting instruments, the exact limit of which we can guide and 
foresee, to the uncertain effects of the ecraseur or constricteur. 

b. Amputation of the Cancerous Cervix by the Galvano-cautery 
Wire. — This was formerly a favorite operation of ours in cases where 
the disease was of the cauliflower variety and entirely limited to the 
intra vaginal portion of the cervix. We have not practised it much of 



Fig. 279. 




Amputation of Cervix by Galvano-cautery Wire. 
(The cervix is not shown diseased in this cut, which is really designed to represent the amputa- 
tion of the cervix in prolapsus* uteri.) 

recent years, because we have not chanced to meet with cases where the 
mere linear amputation of the cervix seemed to offer hopes for a com- 
plete cure, and partly because we have preferred to give the patients 
the greater chances of high excision or complete extirpation of the 
uterus. The diseased cervix is drawn clown by vulsella in the same 
manner as described for the previous method ; the platinum wire loop 
is passed around the cervix on. a level with the vaginal vault, tightened, 
and the current gently turned on, the screw being very slowly moved, 
so as to cut through the part without producing hemorrhage. If the 
cervix has been well drawn down, the amputation usually is effected at 
a higher point than is apparent by sight, so that when the uterus is 
allowed to recede after removal of the diseased portion, a funnel-shaped 
cavity appears; and if the operation has been carefully performed the 
depth of this funnel will usually be at or very near the internal os. The 
disease is therefore, if entirely confined to the cervix, very thoroughly 
eradicated by this method, besides the security against return given bv 



582 CANCER OF THE UTERUS. 

the searing of the wound. Carl Braun 1 is the particular advocate of 
this method, and has reported 156 cases with 9 deaths (6.6 per cent. 
mortality). In 33 cases he found that the disease had not returned 
after one year — that is, 6 per cent. : in 26 cases, or 20 per cent., after 
two years. Two were still well after twelve, and 1 after nineteen ami 
a half years. We (P. F. M.) have had one case of complete recovery 
after amputation with the galvano-cautery loop of the posterior lip of 
the cervix for epithelioma in the third month of pregnancy : the woman 
went to term, had a normal delivery, and the disease showed no signs 
of reappearance one year later. 

c. Destruction of the Diseased Cervix by Means of the Sharp 
Curette, Scissors, and Cautery or Caustics. — This method should 
really appear under the heading of palliative treatment, since only in 
very exceptional cases is a radical cure to be expected from it ; still, 
such does occasionally occur in cases where the disease is limited to one 
lip of the cervix or to the lining membrane of the cervical canal only. 
By a very thorough removal of the diseased tissue by the stiff sharp 
spoon of Simon, followed by the production of a deep slough by the 
thermo-cautery or a saturated solution of chloride of zinc applied on 
pledgets of cotton, the entire destruction of the cancerous tissue may 
be effected. We (P. F. M.) have seen at least one such case in which 
the microscope made the undoubted diagnosis of epithelioma. Of 
course in all these three methods the after-treatment by tamponade 
with iodoform gauze so long as there is any danger of hemorrhage, ami 
the use of milder caustics, such as the stick of nitrate of silver or nitric 
acid, is indicated until whatever raw surface remains is healed. 

As yet authorities are divided as to whether this partial removal of 
the uterus should be practised in preference to the complete extirpation 
of the organ, which latter we will now proceed to describe. 

Hysterectomy, or Complete Removal of the Uterus. — The removal 
of the uterus for cancer may be effected either by abdominal section or 
through the vagina. We need but refer to the former method, since it 
has now been practically abandoned in favor of the very much safer 
and equally efficient vaginal method. Freund of Strasburg was the 
first who in 1878 revived the removal of the uterus through an abdom- 
inal incision, and practised it a number of times. He was followed by 
Schroeder, Billroth, Czerny. and others, but the mortality was so great 
after this operation, and even in the cases of recovery the recurrence 
of the disease so frequent, that it was soon given up. and it may now 
be said to be entirely obsolete. According to Karl von Rokitansky. 
of 95 cases operated upon after Freund's method. 65 died under the 
operation, and of the remaining 30 not one escaped without a recur- 
rence of the disease. 

Vaginal Hysterectomy. — This operation dates back very much 
farther than is generally supposed, since it was first performed by Lan- 
genbeck in 1813. the patient living thirty years after the operation. 
In 1822. Sauter of Zurich performed the same operation, the patient 
recovering, but dying four months later. Blundell repeated the opera- 
tion in 1828. and in 1830. Recamier and Delpech together did the same. 

1 Pawlik, Wiener klinik. December, 1882. 



TREATMENT. 583 

After this time the operation seems to have been more or less forgotten 
until the high mortality of Freund's abdominal method induced Prof. 
Czerny of Heidelberg in 1879 to revive it, in which action he was 
speedily followed by Schroeder, Olshausen, Martin, Billroth, Fritsch, and 
others, until now the statistics of vaginal hysterectomy for cancer foot 
up to a total of many hundreds. Practically, however, the operation 
as now performed is scarcely a dozen years old. 

Indications. — The one chief indication for the complete removal of 
the cancerous uterus through the vagina is the positive and absolute 
limitation of the disease to that organ. As already stated, authorities 
are still in doubt, at least in this country and in England, as to whether 
cancer of the cervix warrants the removal of the entire organ ; in Ger- 
many, with the exception of Carl Braun and possibly some others, the 
question is settled in favor of the complete extirpation. As regards 
the justifiability of removing the whole uterus in cases of cancer of the 
body of the organ there can, of course, be no discussion. It is for this 
special location of cancer that the complete removal of the uterus 
seems expressly indicated. 

Contraindications. — Whenever there is the slightest appearance or 
even suspicion of involvement of the para-uterine tissues (vagina, broad 
ligaments, pelvic cellular tissue, bladder, or rectum) in the cancerous 
degeneration, the removal of the whole organ is absolutely contraindi- 
cated. We are aware that in making this positive statement Ave are 
opposed to the views and practice of many prominent operators, notably 
in Germany, who have often removed the uterus with a portion of the 
diseased adjacent tissues, with a recovery of the patients from the ope- 
ration ; but our experience and logic lead us to except such cases from 
those warranting the operation, since it is scarcely probable, or even 
possible, that the disease can have been entirely extirpated under such 
circumstances. 

Methods. — A number of technically more or less different methods 
of vaginal hysterectomy have been introduced and practised by differ- 
ent operators. Schroeder advised opening the posterior cul-de-sac first, 
retroverting the uterus and drawing the fundus out through the open- 
ing, and then to proceed to ligate the broad ligament on either side 
with several strong silk ligatures and divide the attachments. Finally, 
the anterior cul-de-sac was opened and the bladder detached from the 
vagina. Czerny first opened the anterior cul-de-sac, incised the vaginal 
vault completely around the cervix, pushed up the bladder, opened 
Douglas's pouch, and then retroverted the uterus. Finally, the broad 
ligaments were ligated in from three to six portions on each side, and 
the uterus excised. Olshausen does not retrovert the uterus, but draws 
it down with vulsella inserted into the cervix, incises the vaginal wall 
all around, gradually separates the connections of the bladder and rec- 
tum with the finger, ligates bleeding vessels, opens the peritoneal cav- 
ity in front and behind, and ties the broad ligaments by an elastic 
ligature passed through by means of an aneurism needle, and then 
removes the organ. Peter Muller advised cutting the uterus in half 
and removing each half separately. This method applies chiefly to eases 
where the organ is very much enlarged, and is not generally practised. 



584 



CANCER OF THE UTERUS. 



Fritsch ligates the tissues step by step, first on one side and then 
on the other, drawing the uterus down as far as possible by vulsella, 
and dividing the tissues between the uterus and the ligated portions as 
he proceeds. The anterior cul-de-sac is then opened, the bladder 
pushed up, bleeding vessels secured, the same done to the posterior cul- 
de-sac, and the remaining attachments of the uterus then divided. 

Operation. — The method which we have employed, and which is sub- 
stantially that of Martin and Fritsch combined, is the following : With 
the patient in the lithotomy position the vagina is thoroughly disinfected 
with a 1 : 5000 bichloride solution, gangrenous and infectious portions of 
the cervix having been removed by the curette either previously or at the 
same time. The cervix is firmly seized with one or two vulsella forceps, 
drawn down as far as possible to the vulva, and two deep ligatures of 
stout silk are passed through each lateral vaginal pouch, and tied in 
order to compress the uterine arteries. The cervix being now pulled 
sharply upward, a transverse incision is made well outside of the dis- 
eased tissue in the posterior cul-de-sac, and Douglas's pouch speedily 
opened. The opening is enlarged with the fingers, and the peritoneum 

Fig. 280. 




First Step of Vaginal Hysterectomy (Martin) 



stitched by quite deep sutures of catgut to the vaginal wall. This is 
a very important point, because severe hemorrhage is likely to occur 
from the vessels in the cellular tissue, the blood running into the peri- 
toneal cavity during the rest of the operation and being overlooked. 
We are convinced that two of our fatal results among our early opera- 



TREATMENT. 585 

tions were due to our having omitted to notice this hemorrhage. A 
well-disinfected sponge of the size of an egg, with a long string attached, 
which should be black in order to distinguish it from the ligatures, is 
passed up into the abdominal cavity in order to prevent the intestines 
from coming down. The index finger of the left hand is now intro- 
duced into the abdominal cavity through the opening in Douglas's 
pouch, and the vaginal wall on the left side lifted up sharply (Fig. 280). 
With a stout aneurism needle or a so-called Deschamps needle curved 
toward the left a strong silk ligature is passed about a quarter of an 
inch from the border of the uterus and securely tied, one end being cut 
short. The tissue included by this ligature is now divided by scissors 
and another one applied higher up, and so on until the upper limit of 
the cervix has been reached. The same procedure is now repeated on 
the right side, and when both sides have thus been ligated and sepa- 
rated, the uterus remains attached only by the upper portion of the 
broad ligament and the connection with the bladder. The finger in 
the abdominal cavity now pushes forward the anterior cul-de-sac on one 
side, and an incision is made transversely through the vaginal wall, and 
the bladder pushed up with the index finger of the right hand or with 
the handle of the scalpel, a sound being kept in the bladder at the 
same time for greater safety. The peritoneum between bladder and 
uterus is now sharply pressed upward by the left index finger in the 
abdominal cavity, and opened by scraping with blunt scissors. The 
fingers enlarge the opening transversely, and nothing now remains to 
do except to ligate by successive stages the remaining attachments 
between the uterus and the upper portion of the broad ligament. Usu- 
ally the ovaries and tubes come into view during these last stages if the 
firm traction on the organ, which should be kept up during the whole 
operation, is not relaxed ; and of course it is best to include these 
organs in the ligatures and remove them with the uterus. This is not 
always done, it is true, but we have always endeavored to do it, and 
have usually succeeded. To leave the ovaries behind is simply to sub- 
ject the patient to the annoyance of a continuance of an entirely unne- 
cessary function — namely, menstruation. We have found the last stages 
of the operation — that is, the ligation and division of the upper portion 
of the broad ligaments — to be among the most difficult and misleading 
of the whole procedure ; still, a perseverance on the lines indicated 
above can but result in perfect success. It will be noticed that in this 
description the uterus is neither retro verted nor ante verted, except per- 
haps at the last moment, when the upper portion of the broad ligament 
is divided, but that it is removed in precisely the axis which it occupied 
in the body. 

As soon as the uterus has been removed the anterior peritoneum and 
vaginal wall should be sewed together with catgut, if this was not already 
done when the peritoneum was opened; and it is a good plan to stitch 
the stumps of the broad ligaments to the vaginal incision on either side. 
Any bleeding vessels must be caught up and tied or the blooding stopped 
by sutures passed underneath them, and the operation should not bo con- 
sidered completed until every vestige of bleeding is entirely arrested. 
The sponge is now removed from the abdominal cavity, and it will be 



586 CANCER OF THE UTERUS. 

found that, quite to the surprise of the novice, the opening in the vag- 
inal pouch is comparatively small ; indeed, many operations are per- 
formed without the intestines or omentum ever appearing to view. 
Some operators recommend closing the vaginal vault entirely, but it is 
preferable to provide for drainage, and the majority therefore leave it 
open, packing the vagina lightly with iodoform gauze. The ligatures 
are carried out of the vagina and tied together in bundles, separating 
those of the anterior, posterior, and lateral walls respectively. The 
patient is now put to bed. and an ice-bag may be applied over the 
abdomen if the operator thinks it desirable. The operation, according 
to the skill of the operator and the greater or lesser difficulty of the 
case, may last from twenty minutes to an hour. 

The after-treatment consists in drawing the urine if the patient can- 
not void it herself, keeping her carefully in the recumbent position, 
although allowing her to turn on either side as she desires, moving the 
bowels after the third or fourth day by mild laxatives or enemas, and 
scrupulously avoiding any interference with the gauze packed into the 
vagina until at least the fourth day, even though the gauze may be satu- 
rated by the secretion, usually sanious, from the wound. On the fourth 
day, or perhaps even later, the gauze should gently be removed and 
need not be replaced. Vaginal injections should be scrupulously 
avoided for at least a week, and even then be postponed until the com- 
plete closure of the vaginal vault seems assured. Cases are on record 
where early vaginal injections re-opened adhesions, permitted the 
entrance of the injecting fluid into the peritoneal cavity, and caused 
death. 

In place of ligatures to compress the vessels of the broad ligaments, 
stout long forceps have been used by Pean and Richelot (both of whom 
claim the priority of this suggestion), which are left in situ for from 
forty-eight to seventy-two hours, until complete obliteration of the com- 
pressed vessels has been attained. In using these forceps the posterior 
vaginal vault is first opened, and all bleeding vessels secured by cat- 
gut ligatures, as already described ; the anterior vaginal vault is then 
opened on the finger into the peritoneal cavity, the bladder separated, 
and the peritoneal and vaginal walls sewed together with catgut. The 
broad ligaments having thus been isolated on either side, one large 
clamp is passed from above and the other from below, effectually grasp- 
ing between them all the tissues of the broad ligaments. The uterine 
attachments are then divided, and the same manoeuvre repeated on the 
right side. The handles of the clamps should be secured by ligatures, 
and, if thought best, the blades of the clamps may be prevented from 
slipping by passing a deep silk ligature through the broad ligaments on 
each side and tying it over the clamp. Special clamps of proper thick- 
ness and length have been devised for this purpose by Pean, Richelot, 
Cleveland, Polk, and others. Undoubtedly, there is a great saving of 
time by the use of these clamps, but, unfortunately, not every case per- 
mits of their employment. They are said to produce sloughing and 
adhesions of intestines and omentum to the edges of the wound, and 
hence we believe many operators who formerly employed them have 
returned to the use of the progressive silk sutures as described above. 



TREATMENT. 587 

Some operators have employed as many clamps as appeared necessary 
to compress all bleeding vessels, using a clamp in place of each ligature, 
as described above in the operation practised by us. Thus a dozen 
clamps or more might be left in a wound. The handles are carefully 
protected by being wrapped with iodoform gauze. 

It is curious to notice the entire absence of shock, pain, and of 
any evidence of a severe operation having been performed in the 
patients who have undergone a successful vaginal hysterectomy ; they 
appear like women after a normal labor. It is scarcely safe to allow 
the patient to sit up under two weeks. The ligatures should be 
removed gradually as they become loose, gentle traction being made 
every now and then after the first two weeks. We have seen them 
retained as long as six weeks after the operation, requiring finally to 
be removed by scissors. 

Dangers. — The chief dangers from this operation are — primary and 
secondary hemorrhage, shock, septicaemia, and peritonitis. Both pri- 
mary and secondary hemorrhage can be controlled or guarded against 
by a careful employment of sutures and ligatures, and the precaution 
never to leave the patient until all trace of bleeding has been com- 
pletely arrested. Shock should really never occur, and indeed we 
doubt whether, when it does take place, it is not due to a concealed 
hemorrhage rather than to what is really known as "shock" — that is, 
acute nervous prostration. Septicaemia is of rare occurrence if careful 
antiseptic precaution — that is, irrigation by a very weak bichloride 
solution, 1 : 10,000, or, what is safer and equally good, the Thiersch 
solution — has been kept up during the operation. Peritonitis likewise 
is but rarely to be feared. 

One danger, the avoidance of which lies almost entirely in the 
hands of the operator, is the accidental injury of the bladder and ure- 
ters during the operation. This accident has occurred to some of the 
most skilful operators, and therefore by no means necessarily implies 
carelessness or want of skill on the part of the surgeon. If the blad- 
der is opened, it should be immediately sutured with catgut, and the 
wounded ureter if possible restored to its continuity by the same method. 
Occasionally the ureter has not been wounded, but been included in 
one of the ligatures ; and if this accident has occurred on both sides, 
acute retention of urine and acute uraemia, with convulsions, coma, and 
rapid death, have been the result, the cause of the fatal issue not being 
discovered until the autopsy was made. This accident can almost 
always be avoided if care is taken to push up the bladder sufficiently, 
so that it and the ureters are away beyond the reach of the knife and 
ligatures. 

Results. — The results of vaginal hysterectomy may be divided into 
immediate and remote. 

Immediate results means the percentage of recoveries from the 
operation. While the early operations showed a comparatively large 
mortality, recent statistics seem to prove that the operation is not a 
very dangerous one ; the most recent figures being these of Leopold. 
who out of a total of 80 operations had only 4 deaths, or a mortality 
of 5 per cent. ; Kaltenbach, out of 55 but 2 deaths, or 4 per cent. : Ott 



588 CANCER OF THE UTERUS. 

had 30 operations with no death ; Pean, 25 operations with no death. 
Unquestionably, the percentage of mortality will depend very greatly 
both upon the skill of the operator and upon his choice of favorable 
cases ; still, we have operated on several in which the extension of the 
disease to the broad ligaments (not recognized until during the ope- 
ration) rendered them very unpromising and difficult, with complete 
and uneventful recovery. 

Remote Results — that is, Permanency of Cure. — Accordingly as the 
indication for the performance of vaginal hysterectomy for cancer, 
either of the cervix or body, has been correctly followed, a complete 
cure — that is, non-recurrence of the disease — is to be expected. If 
the operator is perfectly sure that his line of incision has gone through 
entirely healthy tissues, and that he has succeeded in completely extir- 
pating the cancerous material so far as his finger and eye permit him 
to judge, he should reasonably expect to have effected a permanent 
cure. Cancer, being at its outset unquestionably a purely local disease, 
can be undoubtedly permanently cured if all the diseased tissue with 
every possible ramification is thoroughly removed. The difficulty of 
making a correct estimate of the limit of the cancerous infiltration is 
as yet the great obstacle, not only to the formation of an infallible 
indication for hysterectomy, but also to the absolute certainty of a com- 
plete removal of the diseased tissue. Hence for the present it is almost 
impossible for us to say in a large number ol cases Avhether we have 
succeeded by the complete extirpation of the diseased uterus in effect- 
ing a permanent cure or not. Even though we firmly believe that this 
has been the case, Ave may find, to our regret and surprise, that sooner 
or later, even after as long an interval as two or three years, the dis- 
ease reappears at some point of the cicatrix. This recurrence cannot 
be considered in the light of a new cancerous infiltration, but merely 
as a cropping out of latent germs of the disease which were not appa- 
rent at the time of the operation. We are still, therefore, obliged to 
judge of the justifiability of vaginal hysterectomy for cancer and of 
the permanency of the cure thus effected by statistics reported by sur- 
geons who have a large number of cases of this operation to record. 

Among the latest of these series is that published by Leopold, who 
lost but 4 out of 80 vaginal hysterectomies. Of the 76 women who 
recovered, the first dating back five and a half years, 14 have since 
succumbed, of whom 10 only died in consequence of a recurrence of 
the cancer. Of the 62 still surviving, 3 only have been attacked by a 
recurrence ; the others are cured, the time since the operation varying 
from five and a half years to one year and three months. 

Of 76 patients remaining under observation after recovery, there 
were free from recurrence — 



At 



5.1 years . . . 


. . . .3 


At 2.^ years . . 




. 2 


41 « 


'> 


21 " 




9 


3| "... 


. . . .3 


2 " . . 




. 3 


U " ... 


. . . . 1 


n " . . 




. 3 


3J " . . . 


. . . . G 


1} " . . 




. 3 


3 " . . 


. . . . 2 


Between 1 vear 


and 3 months 


. 4 


2f " ... 


. . . . 3 









TREATMENT. 589 

It will thus be seen that 72 of these 76 cases were still well, without 
recurrence of the disease, from one to five and a half years after the 
operation. Certainly, one cannot ask for much better results in a dis- 
ease which invariably proves fatal if allowed to proceed undisturbed. 
Our rather limited experience with vaginal hysterectomy leads us, 
unfortunately, to deplore the fact that we but rarely see cases of cancer 
of the uterus in which the indication laid down in the preceding pages 
can be scrupulously carried out. The vast majority of cases of this 
disease which come to our notice have advanced so far that there is 
little or no prospect of entirely removing the diseased tissue by any of 
the methods which Ave have described. There can, in our opinion, be 
no doubt whatever that if cancer of the cervix or of the body of the 
uterus is observed at a stage so early that the surrounding tissues are 
absolutely healthy, a complete cure can be achieved by an entire 
removal of the affected part or the whole organ. This rule, we 
believe, applies to cancer situated in any part of the body where 
its surgical ablation is practicable without interference with vital 
functions. 

Before concluding the discussion of the justifiability of the radical 
operations for cancer of the uterus, we wish to state our conviction that 
whenever there exists a reasonable chance that the disease can be 
entirely eradicated by the removal of the cancerous cervix or of the 
whole uterus the patient should be given that chance. But we are 
unquestionably of the opinion that to remove the whole uterus, or even 
to perform high amputation of the cervix, when the cancer has already 
invaded neighboring tissues which it is impossible for us to excise or 
destroy, is not only useless, but unjustifiable. Furthermore, we are 
inclined to favor the removal of the entire organ by the vagina even in 
cases of cancerous disease of the cervix alone, rather than to take the 
chances of a high amputation of the cervix when possibly the disease 
has already extended beyond the internal os. The mortality of vag- 
inal hysterectomy (Leopold, 5 per cent.) is so low that it need not be 
feared. 

Merely as a matter of record we will state that Zuckerkandl and 
Woelfler have proposed and practised the removal of the cancerous ute- 
rus by means of an incision made over the sacral region, claiming that 
it is much easier in this manner to expose and extirpate the organ. 
Those operators who have had occasion to perform vaginal hyster- 
ectomy will scarcely find it necessary to adopt this new procedure, and 
it is very doubtful whether it will gain many adherents. 

Palliative Treatment. — As already stated, by far the larger major- 
ity of cases of cancer of the uterus are seen at a stage when the inva- 
sion of the vagina and parametrium by the disease renders a radical 
cure impossible, and restricts us to the mere endeavors to alleviate the 
symptoms of which the patient complains and to prolong her life. 
When the cancerous infiltration or ulceration has spread to the vaginal 
wall ; when the examining finger feels in the cellular tissue about the 
cervix a hard, more or less extensive, infiltration evidently connected 
with the diseased cervix ; when the uterus is immovable in consequence 
of this infiltration or of cellulitis or peritonitis; when the inguinal 



590 CANCER OF THE UTERUS. 

glands are affected (which usually occurs in uterine cancer at a very 
late stage) ; when the pelvic blood-vessels and lymphatics are com- 
pressed or diseased, as shown by oedema of the labia, suprapubic region, 
or thighs ; when the recto-vaginal and vesico-vaginal walls are involved; 
finally, when compression of the ureters by the disease has produced 
dilatation of those ducts and perhaps of the renal pelvis, — in all these 
conditions it is futile to attempt a radical cure. 

But let it not be understood that every case of incurable cancer of 
the uterus necessarily demands active or even surgical interference. In 
many instances the patient suffers very little pain ; there is no bleeding, 
no offensive discharge, for the reason that the extension of the disease 
is submucous or hidden underneath the vaginal walls, and no superficial 
ulceration exists ; or else the spread of the disease is so slow that it 
produces but little inconvenience. In such cases it is far better to 
attempt to build up the health of the patient by general tonics, chiefly 
iron and arsenic, relieve such pain as may come on at times by morphine 
suppositories given as pain may require, by antipyrin or phenacetin, 
than to attempt to arrest the disease by local application of caustics or 
escharotics, which will invariably prove useless. The administration 
of Chian turpentine has been recommended by Clay of Manchester, 
endorsed by a number of others, as a means of arresting the groAvth 
of cancer of the uterus, and indeed entirely curing a certain if small 
number of cases. We have used the drug sufficiently often to feel that 
it, in our hands at least, was entirely devoid of any effect upon the can- 
cer, and indeed of any effect whatever except that of disturbing the 
patient's digestion. We have therefore given up its use. At the time 
of the condurango craze some fifteen years ago Ave were induced to use 
this agent in the shape of an infusion in several cases of carcinoma of 
the uterus, and, while w T e did not see that it exerted any influence on 
the disease itself, its stimulant effect upon the digestive organs was such 
as to, for a time at least, decidedly benefit the patients. We would 
look upon it, therefore, as a gastric tonic, while absolutely disclaiming 
any belief in its efficacy against cancer. Warburg's tincture without 
aloes, in capsules, in doses of one-half to one drachm, three times daily, 
and Huxham's tincture, are excellent remedies to build up the general 
health and increase the blood-supply of the patients. While we have 
mentioned arsenic as a good tonic in these cases, we do not share 
the belief of some — among others the late Dr. Washington L. Atlee — 
that it exerted a specific curative effect upon the cancer-germs. As 
regards the use of opium in cancer of the uterus, we will merely say 
that we give it and allow it to be given in proportion to the necessity 
for it — that is, as required by the pain experienced by the patient. A 
woman who is sure to die within a more or less limited period from 
a very painful disease certainly has a right to expect that her life 
should be made as comfortable as possible during the time which she 
is still to suffer. We therefore allow our patients afflicted with can- 
cer to use their own discretion about the amount of morphine which 
they think they require ; of course always being careful to caution them 
against using more than a perfectly safe quantity in a certain given 
time. Usually we administer the drug in the shape of suppositories, 



TREATMENT. 591 

although some patients become quite adept with the hypodermic 
syringe. 

It is our invariable rule never to acquaint the patient with the nature 
of her disease if we can possibly avoid it. By telling her that she has 
an ulcer, a tumor, a sore, or something of that kind which will require 
speedy operation and perhaps prolonged treatment, we can usually 
escape answering the direct question whether her disease is cancer or 
not. It is simply brutal to deprive a woman of all hope of recovery 
by telling her point-blank that she has cancer, and only when the 
patient insists upon knowing the truth have we deviated from this rule. 

When, therefore, cancer of the cervix or body of the uterus does 
not materially incommode the patient by local manifestations, but is 
merely gradually undermining her health in the subtle manner already 
mentioned as characteristic of this disease, it is best to abstain from 
all local treatment and to confine ourselves to maintaining the tone of 
the general system and to prolonging life by all means at our disposal. 
We have thus seen cases of cancer of the cervix run three and four 
years with comparatively little local disturbance, the patients grad- 
ually emaciating, and eventually dying, from the toxic influence on the 
general health. 

When, however, there is severe hemorrhage recurring more or less 
frequently ; when the disease is spreading rapidly to the neighboring 
parts ; when there is a foul, irritating discharge, whether accompanied 
or not by the evidences of septic infection, — it becomes our duty, in 
our opinion, to endeavor to arrest the process of development and 
control the symptoms to the best of our ability. The methods at. our 
disposal for these purposes are the following : first, curette ; and sec- 
cond, chloride of zinc. The most efficient means at our command for 
the control of hemorrhage from a cancerous cervix or even body of the 
uterus is the sharp curette. With it the bleeding cancerous granula- 
tions or the sloughing gangrenous particles are scraped away, hemor- 
rhage and septic infection are at once arrested, and under appropriate 
after-treatment perhaps permanently removed. Of course the disease 
goes on, but the patient is far more comfortable and her life is pro- 
longed for a certain time. 

Operation. — We usually perform this operation through the Sims 
speculum, although it may be accomplished simply by the touch with 
the patient in the dorsal position ; but we prefer the Sims position, 
because it enables us to see the affected part and afterward to apply 
such caustics as may be indicated. With a stout sharp Simon's scoop 
the cancerous tissues are rapidly and thoroughly scraped away, so that 
in place of a superficial ulceration, or even of a papillomatous growth, a 
more or less deep cavity in the cervix is formed. By using smaller 
curettes the diseased tissue may be thoroughly removed far up into the 
uterine canal, and we have often thus excavated the whole cervix, 
leaving but a shell, the upper limit of which reached within the cavity 
of the' body of the uterus. When all the soft cancerous tissue lias been 
scraped away, which is easily recognized by the curette, and the hard, 
gritting muscular substance of the uterus is reached, the curette should 
be laid aside, and now, the cavity having been thoroughly mopped 
38 



592 



CANCER OF THE UTERUS. 



with cotton or sponge soaked in very hot water and dried, it may be 
cauterized by the Paquelin therino-cautery, or, if one wishes to pro- 
duce gradually an even deeper slough, by the application of the chloride 
of zinc. This is done by inserting small flat pledgets of absorbent cot- 
ton, soaked in a 50 per cent, solution of chloride of zinc in water and 
dried, into the excavated cavity, so as to touch every portion of its 
walls. This should be done rapidly, and the vagina is then carefully 
tamponed with flat pledgets of cotton soaked in a solution of bicar- 
bonate of soda, the object of which is to neutralize any excess of the 
chloride of zinc and to protect the vaginal walls from the possible unde- 
sired action of that caustic. It is well to render these vaginal tampons 
aseptic by means of plentiful distribution of iodoform blown in through 
an insufflator. The tamponade of the vagina may be concluded by a 
long strip of iodoform gauze, which will keep the tampons so sweet that 
they can be left undisturbed for forty-eight or even seventy-two hours. 
Then the vaginal packing should be changed, the zinc pledgets being 
left, and the vagina being repacked with iodoform gauze. In from 
four to six days after the original operation the zinc tampons will be 
found loose and can be removed, and a few days later the slough caused 
by the zinc will be found detached, and can often be lifted out of its 
socket with forceps in one piece. (See Fig. 281.) After this has been 
removed it should be the endeavor of the physi- 
cian to cause the cicatrization of this cavity by 
touching it with nitric acid or with a stick of 
nitrate of silver every few days, and by packing 
it with iodoform and tannin powder, equal parts, 
in order to contract the granulations and prevent 
discharge and hemorrhage. This treatment may 
have to extend over a number of months, but by 
its persistent continuance the disease may be kept 
very much in check, the patient made very com- 
fortable, and her life prolonged by a number of 
months. In spite of this treatment, the granu- 
lations may grow again, and the curretting and 
subsequent application of chloride of zinc require 
repetition once or oftener. But the treatment is 
not very severe, and is usually not attended with 
danger. The sharp curette employed in this man- 
ner was first introduced into practice by the late 
Prof. Simon of Heidelberg, and has been described 
by Munde' in an article entitled " Treatment of Cancer of the Uterus 
with the Curette," published in the American Journal of Obstetrics 
for August, 1872. The additional use of chloride of zinc as a means 
of removing a larger amount of the cancerous tissue than is practicable 
for the curette to do (possibly curing a case here and there) was first 
recommended by the late Dr. Marion Sims (see American Journal of 
Obstetrics, 1879), and has since found many imitators. We are heartily 
in favor of it, and employ it almost invariably after the curette. 

Dangers. — In using the curette the proximity of the peritoneum 
should be borne in mind, and the ease with which the soft cancerous 



Fig. 281. 






s^m^ 




"IK 



Cast of Cancerous Cavity 
of Cervix produced by 
chloride of zinc. (From 
specimen in possession 
of P. F. M.) 



TREA TMENT. 593 

tissue may be removed and the brittle peritoneum be perforated. If 
the accident is at once recognized and the operation suspended, the 
cavity being packed with iodoform gauze, probably no great damage 
will have been clone. Occasionally a large blood-vessel may be opened 
by the curette and a severe arterial hemorrhage result, requiring the 
use of deep sutures or ligatures ; but this is a very unusual occurrence. 
The chloride of zinc also is not without its dangers, since perforation 
of the uterine wall may be produced by a too thorough application of 
the pledgets and a too deep action of the caustic. Two such cases are 
reported by Sims in the article mentioned. We (P. F. M.) have seen 
one instance of perforation of the uterine wall, with collapse and death, 
after the careful use of the curette in the neighborhood of the os inter- 
num, followed by the tamponade with pledgets of cotton soaked in a 
solution of persulphate of iron in glycerin. In this connection we 
desire to warn against the use of the sharp curette and escharotics in 
the uterine cavity in cases where the disease is mostly supravaginal, 
chiefly on account of the danger of perforation just referred to. 

Paquelin Thermo - cautery : — Instead of the chloride of zinc, or, 
if preferred, some hemostatic agent, such as persulphate of iron or tan- 
nin, the cavity excavated by the curette may be thoroughly seared with 
the ball tip of the Paquelin heated to a dull reel heat. This should be 
done very carefully, gently, and so thoroughly as to check all bleeding 
and give the surface of the wound a black color. The cavity may 
then be packed with iodoform and tannin or iodoform gauze. 

It is not always easy to accomplish the arrest of oozing with the 
Paquelin, and a very thorough application of the heat may be required 
to effect this purpose ; and this very thorough application may produce 
a destruction of tissue, as a result of which a slough takes place which 
is deeper than the operator intends, and on the separation of which 
blood-vessels are opened from which a very profuse hemorrhage may 
occur. The Paquelin may also be used without being preceded by the 
curette in cases where the carcinomatous infiltration is flat and not 
excavated, the object being to destroy as much of the diseased tissue 
as possible. 

Danger. — We formerly employed the Paquelin very frequently in 
these cases, but have had an unfortunate experience (P. F. M:), in 
which, after removing the epitheliomatous cervix with the galvano- 
cautery wire, we found it necessary to excavate the remaining portion 
of the cervix with the sharp curette. The Paquelin was then applied 
thoroughly and the patient tamponed. On removing these tampons on 
the second day, absolutely no hemorrhage took place ; hence new tam- 
pons were but loosely inserted ; but immediately after our departure 
the slough produced by the Paquelin in the vaginal vault broke down, 
a furious hemorrhage took place from the pampiniform plexus, which 
resisted all attempts at control by tamponade and pressure, and the 
patient died some twenty-four hours later. Dr. M. D. Mann of 
Buffalo relates an instance in which, after removing the cancerous cer- 
vix with the galvano-cautery wire, he found a small nodule of diseased 
tissue still present on one side of the cervix. This he excised with 
scissors, and thereby accidentally opened an artery of such size that. 



594 CANCER OF THE UTERUS. 

in spite of all his efforts to arrest the hemorrhage, the patient suc- 
cumbed on the table. We do not quote this case as illustrative of 
sloughing after the Paquelin, but merely as an evidence of the profuse 
hemorrhage which may occur from the cervix in these ca*ses and as a 
companion to our own unfortunate experience. 

We would warn, therefore, against an indiscriminate and too deep 
application of the thermo-cautery, for fear of producing too extensive 
sloughing and possibly severe secondary hemorrhage. Furthermore, it 
has seemed to us that the stimulant action of heat tended at times to 
increase the rapidity of growth of the malignant disease ; hence Ave 
confess that we prefer as a rule the chloride of zinc to the Paquelin 
cautery when we wish to produce a slough after curetting. 

It will appear from what we have said above that, after removal of 
the diseased cervix by the galvano-cautery wire, it may still seem 
desirable or necessary to destroy as much of the diseased tissue as pos- 
sible above the line of amputation with the curette, chloride of zinc, or 
Paquelin. 

Nitric Acid. — In many cases of superficial carcinomatous ulceration 
of the vaginal portion of the cervix or of the cervical cavity, in which 
there is but little bleeding- and onlv a serous, more or less offensive 
secretion, the latter may be kept in check and the raw surface incited 
to cicatrization by the free application of nitric acid once or twice a 
week, followed by packing with iodoform and tannin powder. We con- 
sider this a very useful treatment for those forms of incurable carci- 
noma in which the strong palliative remedies above mentioned are not 
required. 

A still milder treatment for similar cases to those just mentioned 
is the introduction, every day or two, of some iodoform and tannin pow- 
der, kept in place by a tampon. By it the secretions are modified, 
controlled, and the growth of the disease materially checked. This 
iodoform and tannin may also be introduced by the patient herself in 
the shape of suppositories made up with cacao butter or gelatin, one or 
two being used each day according to the requirements. 

Accidental hemorrhage occurring during this treatment, or at any 
time during the progress of a case of cancer of the cervix, may be 
checked almost invariably by packing the bleeding cavity with a tam- 
pon soaked in a solution of persulphate of iron in glycerin, equal parts, 
and squeezed dry, or the bleeding cavity may be filled with dry pow- 
dered persulphate of iron, held in place by one or more dry tampons. 
At times, in urgent cases, the ligation of the uterine arteries by deep 
silk or wire sutures passed through each vaginal vault may be required 
to check the bleeding, in addition to the above measures. 

In addition to the perforation and hemorrhage which we have men- 
tioned above, the possibility of the occurrence of peritonitis after any 
of the more powerful applications described should not be forgotten. 
As an instance of this kind we will refer to the case of sequestration 
of the whole of the body of the uterus reported by Munde on p. 575. 

Before concluding this chapter we desire to reiterate the impossi- 
bility of curing cancer of the uterus, as indeed of any other organ of 
the body, unless it is seen at a time so early that complete and absolute 



CO 31 PLICA TIONS. 5 9 5 

removal of the diseased tissue can be effected. Hence we think it our 
duty to impress upon the practitioner the advisability of counselling 
his patients and the laity in general of the importance of an early dia- 
gnosis of cancer, and therefore of the danger of neglecting to consult a 
competent physician whenever the salient symptoms of uterine disease 
manifest themselves. No menstrual period which lasts beyond the 
normal time, no bloody or offensive discharge from the vagina, no per- 
sistent pelvic pain, should be overlooked or considered unimportant; and 
chiefly do these remarks apply to that time of life — the so-called change 
of life — when these irregular, bloody, and serous secretions are sup- 
posed to be natural, but are found on a too late examination to be due 
to cancer, now passed entirely beyond more than palliative help. It is 
surely better that ninety-nine women should be examined and no can- 
cer be found than that one with cancer should allow the examination to 
be deferred until too late. 



Complications of Cancer with Other Tumors of the Sexual 

Organs. 

Fibroids. — It was formerly supposed that cancerous and fibroid 
growths could not and did not develop in the same uterus. This, how- 
ever, has been found to be erroneous, since many cases are on record — 
we ourselves having seen quite a number — where cancer of the cervix 
occurred at the same time with fibroid of the body ; and there is no 
reason why this should not be the case, since the distance between the 
two neoplasms renders an entire different histological change perfectly 
allowable. The change of a fibroid to true cancer is, however, as yet 
questioned, although the sarcomatous degeneration of a fibroma or 
myoma has been repeatedly witnessed. 

Ovarian Tumors. — There is no connection, of course, between a 
cancerous degeneration of any part of the uterus and the development 
of an ovarian tumor. It is only in regard to the question of operation 
that we propose to say a few r words on the coexistence of these two 
affections. Cancer of the uterus, being by far the most important, as 
it is the most rapidly fatal, of the two diseases, requires our chief and 
first attention. If the cancerous uterus can be entirely removed, it 
should be done, the ovarian tumor either being extirpated through 
the vaginal incision at the same sitting, or, if too large, being removed 
by laparotomy before vaginal extirpation of the uterus ; or if this 
appears inadvisable, the uterus may first be removed, and after conva- 
lescence the ovariotomy be performed. A number of cases are on 
record where vaginal hysterectomy and abdominal ovariotomy were 
performed at the same sitting with perfect success. 

Cancer of the cervix complicated with pregnancy lies beyond the 
scope of this w T ork, being in the domain of obstetrics. We will merely 
remark that if a cancer of the cervix be detected during the early 
months of pregnancy, it is usually advisable to remove the cancerous 
disease at once as thoroughly as possible, without reference to the pres- 
ence or persistence of pregnancy. In the cases observed by us abor- 
tion soon followed the removal of the cancerous cervix, with the excep- 



596 DISORDERS OF MENSTRUATION. 

tion of one case referred to in this chapter, where the pregnancy went 
to term and the woman was, so far as we know, permanently cured. In 
the early months, up to the third or fourth, the removal of the whole 
uterus per vaginam has been performed a number of times. 



CHAPTER XL. 

DISORDERS OF MENSTRUATION. 

The process of menstruation, by which the human female discharges 
from the uterus a certain amount of blood once in every lunar month, 
depends upon three phenomena which are intimately connected : 1st, the 
spontaneous escape of one or more ovules from the ovaries ; 2d, engorge- 
ment of the erectile vascular stratum surrounding and supplying the ute- 
rus ; and, 3d, transudation of blood from the vessels supplying the endo- 
metrium. 

Until the year 1821, when Power first broached the subject, the 
connection between ovulation and menstruation was unsuspected. Even 
then it was not established until the writings of Negrier in 1840. After 
this the investigations of Pouchet, Bischoff, Coste, and Raciborski car- 
ried conviction to the minds of most and caused the general acceptance 
of the theory. 

Even to the present day the exact relation between ovulation and 
menstruation is still a matter of dispute. The generally accepted view 
of the case is, that the ripening and dehiscence or expulsion of ova are 
necessary to the inception of the first menstrual period, but that, once 
the ovaries having assumed their physiological function of preparing 
and discharging ova at certain intervals, the process of menstruation — 
that is, the monthly discharge of blood from the uterine mucous mem- 
brane and tubes — goes on more or less independently of the periodical 
ripening and expulsion of ova from the Graafian follicles. Thus the 
inception of the process of ovulation may be considered necessary to 
the inauguration of the menstrual function, but after that period both 
occur more or less independently of each other. That this view is 
correct, or at least has the greater weight of evidence in its favor, is 
proved by the undoubted discharge of ova from the Graafian follicles 
at other times than before, during, or immediately after the regular 
menstrual epoch, and even at times when menstruation is entirely 
absent, as during lactation or when amenorrhoea has for some reason or 
other existed for several months. That conception frequently takes 
place while menstruation is suppressed during lactation, and has even 
occurred before menstruation had ever appeared, is well known and 
cannot be disputed. In order that conception should occur under such 
conditions, ova must have been discharged from the ovary and received 
into the Fallopian tube ; hence the occurrence of ovulation without men- 
struation in such cases is proved beyond a doubt. Further, after the 



DISORDERS OF MENSTRUATION. 597 

removal of both ovaries and tubes the menstrual period has been 
known to occur with more or less regularity in many cases. We our- 
selves have found that this function has been maintained for a variable 
length of time in about 4 per cent, of our cases of removal of the ova- 
ries and tubes. It is most probable that ova are discharged from the 
Graafian follicles at indefinite periods, such discharge being often has- 
tened by some accidental excitement, chiefly of a sexual nature. Some 
authorities have advanced the theory that the ovum is expelled from 
the Graafian follicle usually just before the menstrual period or during 
the height of that function, and that conception, therefore, is most 
likely to occur soon after the cessation of menstruation. Loewenthal 
has proposed the hypothesis that the ovum reaches the uterine cavity 
unimpregnated — that if impregnated at this time menstruation does not 
occur, and the ovum settles itself in the new-formed mucous membrane 
prepared for the next menstrual period. If, however, impregnation 
does not take place, the ovum perishes, and its death causes an active 
congestion which is followed by a flow of blood — that is, the menstrual 
hemorrhage. This theory might explain those cases of impregnation 
just before an expected menstrual period, which then does not occur. 
These are the cases in which pregnancy is supposed to have gone 
beyond the natural limit of 280 days, since the reckoning was taken 
from the last menstrual period, whereas conception did not take place 
till about three weeks later. The probability of ovulation occurring 
between the menstrual periods, and indeed at almost any time under 
special excitement, explains the possibility of conception at almost any 
moment except during the existence of the menstrual flow. 

Formerly it was believed that the superficial layers of the mucous 
membrane of the uterus, which membrane had become enormously 
hypertrophied, prior to the expected menstrual period underwent a pro- 
cess of fatty degeneration, and were exfoliated to a certain depth and 
regenerated after the cessation of the flow. In this manner the easy 
rupture of the weakened blood-vessels was explained ; but later obser- 
vations, particularly by Ruge and Moericke, show that intact ciliated 
epithelium exists on the mucous membrane of the menstruating uterus, 
and that, therefore, no fatty degeneration and desquamation of the epi- 
thelium of that membrane takes place. The discharge of blood must 
therefore be by the process of diapedesis or transudation without rup- 
ture of the vessels. We ourselves have seen this take place in an 
inverted uterus. 

Menstruation ordinarily begins at the age of thirteen to fifteen, 
varying in different nations and climates, and continues with more or 
less regularity in perfect health every twenty-eight days during the 
entire childbearing life of the female — that is, up to about forty-five 
years — with the exception of the periods of pregnancy and lactation. 
The menstrual period lasts in health from three to five days usually, 
should physiologically be entirely devoid of pain or discomfort, and the 
amount of blood lost should in no way weaken or inconvenience the 
woman. Unfortunately, these physiological conditions under the strain 
of our present civilization are seldom met with. While menstruation 
not infrequently occurs during lactation, we ourselves cannot say that 



598 DISORDERS OF MENSTRUATION. 

we have ever seen a case in which the regular occurrence of the men- 
strual flow took place for several months in succession during normal 
pregnancy. When such bloody discharges were reported to us during 
pregnancy, we have invariably found them to be due to some patho- 
logical condition of the cervix or body of the uterus, chiefly to the 
presence of a lacerated and eroded cervix or to an impending mis- 
carriage, and usually the hemorrhages were irregular in their appear- 
ance, and not periodical like those of normal menstruation. 

Just before and at the time of the normal menstrual period there 
exists a certain amount of vascular and nervous tension throughout the 
body, which manifests itself by certain feelings of malaise with which 
all physicians are familiar. These are more or less physiological, and 
mostly cease when the flow has been properly established. Before the 
appearance of the bloody discharge the breasts often swell, become 
tense, and in some cases lumps appear in them, which are simply the 
congested lobes of the gland, and must not be taken for tumors, since 
they usually disappear as soon as menstruation has fairly begun. There 
is also an increased hyperemia of the pelvic organs, with more or less 
profuse secretion just before the menstrual period. 

As already stated, the time of recurrence of normal menstruation is 
every twenty-eight days ; many women, however, in perfect health men- 
struate a few days sooner or later, and accidental influences may either 
anticipate or postpone a menstrual period by a few days or a week. We 
(P. F. M.) have seen two cases, sisters, in whom the menstrual period, 
after being regular for a number of years, during which one of the 
ladies bore several children, for some reason ceased for a period of five 
and nine years respectively, both ladies being in perfect health ; then 
reappeared, impregnation taking place in the one who had borne chil- 
dren before. We consider this a very unusual observation, and men- 
tion it merely to show how uncertain a factor the regularity of the men- 
strual discharge may occasionally be. 

The menstrual blood is usually of a dark color and has a peculiarly 
unpleasant odor, probably due to the retention of the discharge in the 
uterus and vagina when the woman is in bed, and the decomposition 
of the blood by the acid secretions of the vagina. Many women men- 
tion the fact of their passing coagula as something unusual and worth 
recording. If such coagula, are passed with pain, it means that the 
blood is retained in the uterine cavity and coagulates there until the 
organ expels it by contractions which cause the pain. This would 
indicate the probability of a constriction or flexion of the canal ; but 
ordinarily menstrual coagula only mean the accumulation of blood in 
the vagina over night, where it naturally coagulates, and is expelled in 
the morning when the woman uses the vessel. 

We have already said that apart from a certain feeling of general 
discomfort, pelvic weight and bearing down, and nervous irritability, 
normal menstruation should produce no special pain or discomfort. 
But, unfortunately, the function is by no means so normal, regular, 
and physiological as Nature had intended that it should be. This may 
be due to the high tension put upon the constitutions of our women by 



MEN OP A USE. 599 

the requirements of our present civilization ; by -which we mean to 
convey, among the higher classes of our society, the pressure of social 
duties, the cares of housekeeping, the constant mental and physical 
strain upon the large majority of our city ladies ; and in the lower and 
country population the necessity for hard work, often insufficient nour- 
ishment, together with the frequently recurring duties of maternity 
which the poorer classes seem for some mysterious reason particularly 
subject to. 

Menopause. — The "change of life," climacteric, or menopause is 
the period when the function of menstruation, and usually also that of 
ovulation, ceases. The average duration of the childbearing period is 
thirty-three years, according to the investigations of Raciborski, and 
the average inception of the menopause is between the forty-fifth and 
forty-seventh years. Some women cease to menstruate as early as forty, 
and some go in perfect health beyond fifty. A certain hereditary dis- 
position seems to be present in these cases, particularly those of lat< 
menopause. If the menopause occurs earlier than the fortieth year- 
and we have seen it as early as the twenty-sixth year — it is usually due 
to superinvolution and atrophy of the ovaries commonly following par- 
turition, and is not a physiological event. The period of the meno- 
pause may extend over several years, menstruation gradually becoming 
more and more irregular, and finally ceasing entirely, or growing more 
profuse, skipping several months, and then reappearing, this process 
being repeated a certain number of times until finally the flow ceases, 
or it may occasionally stop suddenly. The more gradually the function 
ceases, the less the constitutional, chiefly nervous, disturbances ; and the 
greater the irregularity of the disappearance of the menstrual flow, the 
greater also the hysterical, neurotic, and vascular disturbances in other 
parts of the body. Among the common symptoms of the menopause 
are hot flashes through the head and face, headaches, meteorism, irreg- 
ular congestion of the skin of different parts of the body, feelings of 
numbness, and other neurotic disturbances of a similar nature. The 
mind may be affected at this time, either temporarily or even perma- 
nently, but as a rule all these disturbances gradually cease after the 
disappearance of menstruation and the patient soon returns to perfect 
health. The irregularity and uncertainty of amount of the bloody dis- 
charges during the months or years occupied by the change of life 
should not allow either the woman or the physician whom she may con- 
sult to be misled, and to attribute profuse irregular hemorrhages and 
other more or less remote mysterious symptoms entirely to this physio- 
logical period. We have already remarked that but too often the mis- 
take is made of attributing such hemorrhages to the climacteric, when 
in reality they were due to rapidly progressing malignant disease of the 
uterus. 

The common disturbances of the function of menstruation are — 
first, those in which it is entirely absent or suppressed for a time ; 
second, those in which it recurs too frequently and profusely ; 
third, in which it is associated with pain ; fourth, in which it is accom- 
panied by the discharge of a portion of the lining membrane oi the 
uterus. 



600 DISORDERS OF MENSTRUATION. 



Amenorrhcea. 



Definition. — Amenorrhoea, a term derived from a, privative, fiyv, "a 
month," and psco, "I flow," implies an absence of the menstrual flow 
in a woman in whom it should naturally exist. Such an absence before 
puberty, after the menopause, or during pregnancy and lactation is the 
normal condition, and hence does not come within the definition. 

The absence of menstruation may be either temporary or permanent. 
In the first case it is called suppressio mensium ; in the second, amen- 
orrhcea. 

Suppression of Menstruation may occur as the result of — 

1. Pregnancy ; 

2. Exposure to cold during a menstrual period ; 

3. Some sudden mental or physical shock ; 

4. Rapidly-increasing obesity ; 

5. Luxurious living and want of exercise ; 

6. A serious illness or some wasting constitutional disease : 

7. Discharge of blood from other organs of the body at more or 

less regular, periodical intervals. 

1. Pregnancy. — The suppression of menstruation as a result of con- 
ception is a physiological condition, and need not be mentioned, except 
to inculcate upon the practitioner the necessity of assuring himself that 
in any case of cessation of menstruation which may come to his obser- 
vation, that cessation may not be due to the existence of pregnancy. 
Irrespective of the statements of the patient, a careful bimanual exami- 
nation of the size and outline of the uterus, together with inspection 
of the breasts, ought to suffice for a correct diagnosis. 

2. Exposure to Qold during a Menstrual Period. — This is undoubt- 
edly a very frequent cause of menstrual suppression, which usually lasts 
only a short time, and probably rarely extends over more than one 
menstrual period. In young girls it would not call for any special anx- 
iety or treatment, usually taking care of itself at the advent of the 
next period ; but such a suppression, if very violent, might readily 
result in the production of an acute endometritis or an acute inflam- 
mation of the tubes, ovaries, or peritoneum. 

The treatment would consist in hot applications to the hypogastrium, 
warm sitz-baths, warm vaginal injections, sinapisms to the thighs and 
calves, saline laxatives, and the administration of binoxide of roan^a- 
nese in two-grain gelatin-coated pills, one or two after each meal until the 
flow is established. In married women it would be well to mistrust the 
history of suppression as the result of cold, since conception may very 
readily have taken place. Usually the binoxide of manganese does not 
exert an injurious effect upon an incipient pregnancy; still, we have 
reason to believe that it may possibly bring on miscarriage at a very 
early period, and we therefore counsel caution in its use in a doubtful case. 

3. Some Sudden Mental or Physical Shock has often been known 
to check a present menstrual flow or prevent its appearance at one or 
more subsequent periods. Such shocks may be either of a pleasurable 
nature or the reverse. 

Treatment is usually symptomatic, and, the possibility of pregnancy 



AMENORRHEA. 601 

being eliminated, there is no haste in securing a reappearance of the 
function, which will usually return of its own accord in the course of* 
time. If the non-appearance of menstruation should seem to cause men- 
tal or physical disturbance, the regular administration of the manganese 
pills above mentioned, continued during the whole intermenstrual period 
or for several months in succession, together with massage, exercise, chiefly 
equestrian, would be indicated. In married women the performance of 
the marital function will often result in a return of menstruation. 

4. Rapidly -increasing Obesity. — There seems to be a mysterious re- 
lation between a rapid accumulation of adipose tissue in young women, 
mostly soon after marriage, and a diminution in amount of the flow, 
often associated with irregularity, lengthened intervals between the 
periods, and at times complete cessation for a number of months. This 
relation has been noticed by many writers, especially by those who 
have the opportunity to see women who come under treatment for the 
cure of general obesity. Sterility is almost invariably present in these 
cases. We have seen so many instances of this kind that we have 
arrived at the conclusion that the greater the amount of obesity in 
sterile women, the more pronounced is the irregularity and scantiness 
of menstruation, and to look upon the solution of the difficulty as 
depending not upon the re-establishment of a regular and normal 
menstrual flow so much as upon the diminution of the adipose tis- 
sue. If the latter can be done, the menstrual flow will usually resume 
its normal periodicity and abundance. It seems to us as though the 
nutritive energies of the body have become diverted mainly to the pro- 
duction of fat, to the detriment of the vascular and nervous supply 
normally directed to the sexual organs. 

The treatment in such cases should aim first at a reduction of the 
obesity by diet, exercise, and saline laxatives (a cure at Marienbad, for 
instance), and second at a stimulation of the uterus and ovaries, chiefly 
by the local application of the faradic current. Both these courses of 
treatment may be carried on at the same time. Still, we believe that 
the first plan of treatment — that is, the reduction of general obesity — 
jf successful, will usually result in a re-establishment of the normal 
menstrual function without any special local treatment. We (P. F. M.) 
have met with an instance where a woman soon after marriage became 
enormously stout, increasing from one hundred and twenty to two hun- 
dred and fifty pounds ; menstruation became less and less regular and 
more and more scanty, until finally the lady would skip five or six 
months without a single sign of the menstrual flow or even a molimen. 
Of course she was sterile during all this time, which extended over a 
period of eight years. By means of a strict anti-fat regimen and the 
stimulation of the pelvic organs by the faradic current applied with the 
sound in the uterus, the sponge over the abdomen, three times a week 
for about six months, the woman's weight was reduced by at least fifty 
pounds, menstruation became regular, and conception soon took place. 
After a premature delivery from accidental causes the condition of 
obesity and menstrual suppression returned, but was cured by the 
resumption of the same treatment for several months, and conception 
again occurred. 



602 DISORDERS OF MENSTRUATION. 

5. Luxurious Living and Want of Exercise are common causes of 
temporary suppression of menstruation, and are therefore found mostly 
in the higher classes. The remedies are self-evident. 

6. A Serious Illness or some Wasting Constitutional Disease may, 
through a depreciation of the vital forces caused by malnutrition and 
general anaemia, bring about a temporary suppression of menstruation. 
Thus, pelvic peritonitis, puerperal septicaemia, typhoid fever, pneumonia, 
pulmonary phthisis, general nervous prostration, chlorosis, etc. may 
have such a result. Of these diseases, chlorosis is one of the most 
common. It occurs in young girls approaching or entering the period 
of puberty, and consists in a general anaemia, due to a deficient supply 
of red corpuscles. It may continue for several years, and at times, 
instead of producing suppression of menstruation, may, by the weaken- 
ing of the coats of the vessels and the thin character of the blood, be 
attended by too profuse menstruation. In either case the treatment 
will consist in endeavoring to improve the quality of the blood, chiefly 
by the administration of chalybeate tonics, together with such measures 
as will tend to build up the general health of the patient. 

7. Discharge of Blood from other Organs of the Body at more or 
less regular periodical intervals. Occasionally a woman, instead of the 
regular monthly discharge from the uterus, loses at the same regular 
intervals a proportionate amount of blood from another organ, which 
discharge seems to take the place of normal menstruation. This is 
called vicarious menstruation. These periodical discharges of blood 
may take place from the rectum, the bladder, the lungs, the stomach, 
the nose (most frequently), or from certain portions of the skin (lips, 
fingers, nipples). This diversion of the normal menstrual flow does not 
seem to interfere with the health of the patients, nature appearing 
satisfied with the regular periodical abstraction of blood without refer- 
ence to the organ from which it takes place. Still, such patients are 
dissatisfied with their condition and desire to be like other women. 

Treatment should be directed toward stimulating the sexual organs 
to a proper performance of their functions, and the faradic current, 
applied as already indicated, will form the most potent agent for this 
purpose. Success, however, of such treatment is by no means assured. 

The practitioner should be careful to study the nature of such cases 
thoroughly, in order not to mistake a hemorrhage from one of the 
above organs, occurring at regular intervals of four weeks, for possible 
disease of the rectum, stomach, lungs, etc. 

Frequency. — With the exception of vicarious menstruation, all the 
above causes of the temporary suppression of menstruation occur very 
frequently, and are liable to be encountered by any physician who is 
engaged in general practice. Their nature and treatment should there- 
fore be familiar to all the readers of this work. 

Irregular and Scanty Menstruation. — Although not coming 
properly under the head of either partial or complete amenorrhea, we 
think it worth while, on account of the great frequency of this form of 
disturbance of menstruation, to call attention to it in a separate section. 
By reference to the preceding pages it will be seen that mention has 
already been made of some of the causes to which gradually increasing 



AMENORRHEA. 603 

irregularity and scantiness of the menstrual flow may be due, chief 
among which is that of obesity, mostly in young, recently-married 
women who at the same time are sterile. The peculiar relation between 
obesity and deficient ovulation and menstruation has there been pointed 
out. The health of the women in these cases is usually quite good, 
and they consult the physician more on account of irregularity and the 
sterility than because they have any decided complaint. Usually such 
women are anaemic, and general anaemia, whether attended with or 
depending upon any constitutional disease, is another very common 
cause of this particular form of menstrual disturbance. 

The treatment of such cases will of course depend upon the removal 
of the cause, and has been outlined in a general manner in the preced- 
ing section. 

Amenorrhea or Complete Suppression. — Complete absence of 
the menstrual function for a period exceeding one or more years may 
properly be considered as more than a temporary suppression, inasmuch 
as it usually depends upon some organic disease of the sexual organs 
or indicates the arrival of the menopause, whether premature or at its 
normal time. Complete amenorrhcea may result from the following 
pathological conditions of the generative organs : 

Absence of uterus or ovaries ; 

Rudimentary uterus or ovaries ; 

Occlusion of uterus or vagina ; 

Uterine atrophy ; 

Pelvic peritonitis ; 

Atrophy of both ovaries ; 

Cystic degeneration of both ovaries ; 

Removal of both ovaries ; 

Removal of the uterus. 
The absence of the uterus or ovaries is by no means so rare as has 
been supposed. We have seen a fair number of cases of entire absence 
of the ovary, although complete absence of the uterus is not quite so 
frequent, since even where the ovaries are entirely wanting a slight indu- 
ration similar to an accumulation of a number of muscular or elastic 
fibres situated in the median line at about the middle of the pelvic cav- 
ity can be detected by careful bimanual examination through rectum 
and abdominal wall or bladder. While this indefinite little body can 
hardly be called a uterus, still, embryologically, it answers to that name. 
We (T. G. T.) have seen one instance, presented by the late Isaac E. Tay- 
lor to the Obstetrical Society of this city, in which no trace of the 
uterus could be detected upon the closest scrutiny of the parts removed 
post-mortem. A rudimentary condition of the uterus and ovaries is much 
more common, the uterus being merely a small solid body of the size 
of a filbert, the ovaries not larger than a bean and distinguishable only 
on careful bimanual examination per rectum ; for in many of these cases 
the vagina is absent. We (P. F. M.) remember seeing such a case a tew 
years ago at the New York Polyclinic in the person of a young buxom 
Irish girl twenty-one years of age, who presented herself because she 
had not yet menstruated. The external genital organs were perfectly 
normal, but there was* entire absence of the vaginal canal. Per rectum 



604 DISORDERS OF MENSTRUATION. 

and bladder a small uterus of the size mentioned could be felt, and indis- 
tinct traces of tlie ovaries. An artificial vagina was made for her. the 
uterus opened and sewed to the new canal, but under anaesthesia it was 
found that the ovaries were entirely too small to justify any hope of 
their being developed to functional activity by treatment. 

Occlusion of the uterus or vagina may result in amenorrhcea for a 
number of months or even a year or more, the menstrual blood being 
secreted and retained within the imperforate canals. This condition 
has already been described under the heading of Atresia Vaginae and 
Hematocolpos and Hematometra. 

Uterine atrophy occasionally follows normal labor or abortion, or an 
operation on a lacerated cervix, or the removal of a uterine fibroid, or 
occasionally some form of wasting constitutional disease. 

Atrophy of the uterus following abortion or labor at term is called 
superinvolution. and may occur almost at any time during the child- 
bearing life of the female. 

Pelvic peritonitis may produce complete amenorrhcea by obstructing 
the discharge of ova from the Graafian follicles, and inducing gradual 
shrinking and atrophy of the ovaries through their compression by the 
contracting pelvic adhesions thrown about them. 

A temporary suppression of menstruation, so frequently met with in 
the later stages of pelvic peritonitis, is not produced by this cause, being 
due to the general anaemia of the patients in protracted cases of this 
disease. 

Atrophy of the ovaries may also be caused by certain febrile exanthe- 
niatMiis diseases, such as typhoid fever, scarlatina, variola, measles, which 
bring about a shrinking of other glands of the body. Parotitis seems 
also to have such an effect by metastasis as it has on the testicles in the 
male. We (P. F. M.) remember having a lady of thirty-nine years 
under our care who had never menstruated, having experienced a severe 
attack of typhoid fever in her fifteenth year. The ovaries could be felt. 
but were obviously atrophied, and no menstrual molimen had ever been 
experienced. 

Cvstic defeneration of both ovaries, if very extensive in decree, 
might possibly produce complete amenorrhcea. Still, we have seen so 
many instances of double ovarian tumors where scarcely any vestige 
of normal ovarian tissue could be detected, either macroscopic-ally or 
microscopically, after the removal of the tumors, and where menstrua- 
tion persisted with perfect regularity, that we do not know where to draw 
the line between the complete destruction of normal ovarian substance 
and the persistence of more or less of its physiological elements in such 
cases. We (P. P. M.) have even seen one case of double dermoid tumors 
where nothing whatever of the normal tissue of the ovaries could be 
found, and still pregnancy in the fifth month existed. 

Removal of both ovaries would seem to be sufficient to ensure the com- 
plete cessation of the menstrual flow, especially if. as is nowadays done 
universally, the tubes are at the same time ablated : but we have already 
mentioned that the menstrual function in a certain number of cases, about 
4 per cent, in our experience, after double oophorectomy continues for 
a variable length of time. This curious phenomenon has been differ- 



AMENORRHEA. 605 

ently explained, some claiming that it is due to a long-established habit 
of nature ; others, that a small portion of one or the other ovary has 
accidentally been left behind ; others, that the tubes were not entirely 
removed ; others, finally, that a third or supplementary ovary existed 
and was overlooked. Which of these theories is correct we do not pre- 
tend to say, since either one of them may explain any given case. In 
our experience those cases have been most prone to this persistence of 
menstruation where the appendages were diseased and more or less 
adherent. 

After removal of the uterus, the ovaries being left behind, menstru- 
ation may entirely disappear for a time, and then return from the vagi- 
nal cicatrix, the umbilicus, or some other portion of the body ; or the 
ovaries may shrink and menstruation be permanently absent. 

Significance of Amenorrhea. — The significance of amenorrhoea 
depends more or less upon the cause. In the cases where the generative 
organs are congenitally absent or imperfectly developed, the absence 
of the menstrual function need not produce any unpleasant or detri- 
mental effect whatever upon the patient, who may otherwise be per- 
fectly developed and in robust health. 

Retention of the menstrual blood by occlusion of the vagina or 
uterus will of course produce pains recurring at regular intervals, 
abdominal distension, and a corresponding amount of constitutional 
disturbance. The complete suppression of menstruation in cases where 
it has existed for a greater or lesser duration of time, and has become a 
well-established function, is, for a time at least, attended by unpleasant 
symptoms, particularly if more or less regular evidences of its attempted 
recurrence are present. Such symptoms are — frequent rushes of blood 
to the head, vertigo, hot flashes through the head, chest, and abdomen, 
nervousness, hysteria, hysterical and hystero-epileptic attacks. These 
are the symptoms which have been mentioned as often preceding and 
attending the normal change of life, and are similar to them in their 
causation and character. These symptoms are very commonly witnessed 
for some time — six months to a year or more — after the removal of the 
ovaries for disease of those organs or in order to bring about the early 
menopause. 

Among the laity the impression prevails very largely that a tempo- 
rary or complete suppression of the menstrual function is likely to pro- 
duce some dangerous constitutional disease, such as chlorosis, phthisis, 
dropsy, nervous depression, etc. This is, however, by no means the 
case, since it is not the suppression of menstruation which is the cause 
of the evils feared, but entirely the reverse ; the constitutional disease 
in the cases referred to being the cause for the menstrual suppression, 
which can only be removed by first curing the cause. The non-appear- 
ance of the menstrual function in girls of fifteen or sixteen years often 
alarms anxious mothers, but there is really no cause for such anxiety 
in the vast majority of cases, since even quite healthy girls do not always 
begin to menstruate at the usual physiological age of from thirteen to 
fifteen. Should the function be delayed until the twentieth year or 
even later, and absolutely no sign of its appearance manifest itself, it 
is not improbable that some defect in the development of the genital 



606 DISORDERS OF MENSTRUATION. 

organs is present. We (P. F. M.) have seen during the past year two 
girls, one eighteen, the other twenty years of age, both perfectly devel- 
oped, handsome, with well-formed external genital organs and appa- 
rently normal pelvic dimensions, but almost complete absence of the 
mammary glands, in whom both uterus and ovaries were practically 
absent, the vagina forming but a small blind pouch. Of course the 
true condition of such cases can be ascertained only by a local exami- 
nation, the importance of which is emphasized by the case of tw T o sis- 
ters (sic !) in Newark, N. J., who, having passed the twentieth year 
without any sign of the menstrual function, were finally, after years 
of thorough and manifold medicinal treatment by various practitioners, 
examined by one who suspected something wrong, and found to be her- 
maphrodites — that is, hypospadiac males. 

The diagnosis of the causes of amenorrhea, both incomplete and 
complete, should therefore not be made merely upon the statements of 
the patients or upon general symptoms, but always on the basis of a 
careful local examination, if necessary under anesthesia. Examination 
not only per vaginam, but also with the finger in the rectum and the 
sound in the bladder, aided by the hand on the abdomen, may often 
be required to arrive at the precise condition of the internal genital 
organs. 

Treatment. — The treatment of complete amenorrhea depends entirely 
upon the nature of the cause of the affection. Absent or rudimentary 
uterus and ovaries are entirely beyond the reach of our therapeutical 
resources, with the exception of such cases of rudimentary uterus and 
ovaries in which the organs are at least developed to two-thirds their 
normal size at puberty. Then an attempt may be made by repeatedly 
dilating the uterus with tupelo or laminaria tents, stimulating its cavity 
by applications of carbolic acid and by the intra-uterine and abdominal 
use of the faradic current every other day during a number of weeks or 
months to incite both uterus and ovaries to an increased development. 
If molimina of more or less regularity exist, some success may be 
expected from this treatment, but if the ovarian function is absolutely 
dormant, this or any other kind of treatment will usually end in failure. 
Of course, in addition to local stimulation the circulation of the body 
should be aided by massage, walking, horseback exercise (other circum- 
stances permitting), iron, strychnine, phosphorus in well-borne combina- 
tions, sea-bathing, gymnastics, nourishing food, chiefly meat and milk 
diet, regulation of constipation, etc. Marriage has been recommended 
as a. stimulant to the dormant sexual organs, and if likely to prove suc- 
cessful would undoubtedly be a very proper course to advise ; but should 
it prove unsuccessful, both parties would be left worse off than if they 
had not married. It is therefore, in our opinion, generally too risky, 
because too uncertain a plan to follow. 

Occlusion of uterus or vagina is to be treated on the surgical princi- 
ples laid down in the respective chapter. 

Uterine atrophy, if not of too great an extent — that is to say, if the 
uterus does not measure less than two inches — may possibly be overcome 
by the same local stimulant treatment mentioned above. It will depend 
upon the individual case and upon the persistence of the function of ovu- 



MENORRHAGIA AND METRORRHAGIA. 607 

lation, as shown by the menstrual molimina, whether it is worth while to 
subject the patient to a prolonged course of the necessary treatment. 

When in these cases of complete amenorrhcea dependent upon atro- 
phic uterus or dormant ovaries a certain amount of pelvic hyperemia 
appears to exist, this may be increased, and possibly thereby the men- 
strual function induced, by cupping or scarifying the cervix uteri at 
repeated intervals, usually several times during the month, and chiefly 
every four weeks at the time when a menstrual molimen makes its 
appearance. The abstraction of a small amount of blood in this man- 
ner, by unloading the distended vessels, seems to induce a fresh deter- 
mination of blood to the pelvis, and at times this is followed by what 
appears to be a more or less normal menstrual flow. The cupping may 
be performed by scarifying, and then applying a hollow tube with a suc- 
tion pump made for this purpose to the cervix. Further, in cases where 
electricity cannot be employed frequently, an intra-uterine stem composed 
of alternate beads of zinc and copper may be introduced into the uterus 
and worn for several months, for the purpose of exerting a galvanic 
action upon the organ and stimulating it to increased growth. Very 
good reports have been given of this last-mentioned method of treat- 
ment ; but it, like all others, will be productive of benefit only in cases 
where the ovulation, although dormant, still persists. 

Compression or atrophy of the ovaries produced by their being 
imbedded in pelvic exudations following pelvic peritonitis is usually 
beyond our reach. Only in the earlier cases may appropriate local 
treatment, by means of iodine to the vaginal vault, glycerin tampons, 
hot douches, salt and brine injections, sitz-baths, and local galvanism, 
perhaps gradually produce absorption of the exudation, and set the ova- 
rian surface sufficiently free to permit of the discharge of ova and the 
normal development of the organ. In old cases absolutely nothing can 
be done to effect a cure. 

Cystic degeneration of the ovaries is likewise beyond our reach, so 
far as any treatment for the relief of the amenorrhcea goes. The 
removal of the diseased organs will, of course, only confirm the amen- 
orrhcea. 

Menorrhagia and Metrorrhagia. 

Definition — The first of these terms is employed for the designation 
of a profuse and excessive flow of blood at the menstrual periods ; the 
second for any flow of blood, whether profuse or not, during the inter- 
vals. A patient who menstruates too profusely is said to suffer from 
monorrhagia, while one who loses blood not only at menstrual periods, 
but in the intervals, is said to suffer from metrorrhagia. 

Frequency. — Both these conditions are necessarily frequent, for they 
are symptomatic of a large number of functional and organic affections 
of the uterus. The uterus is the only organ in the body from which 
blood flows as a physiological process. Many organs and all the erectile 
tissues are subject to normal congestions, but from none except the 
uterus is a flow of blood ever other than a morbid process. It is not. 
then, astonishing that in this organ slight and numerous causes arc apt 
to excite hemorrhage. 

■M) 



608 DISORDERS OF MENSTRUATION. 

Pathology. — First, any condition which induces a state of active or 
passive congestion of the uterine parenchyma or lining membrane ; 
second, any influence creating a solution of continuity upon its mucous 
surface ; third, any growth which, having a vascular connection w T ith 
the uterine vessels, allows of a percolation through its tissues and from 
its circumference ; and fourth, any agency producing dyscrasia of the 
blood, — may result in these disorders. Any one of these conditions 
existing alone may produce the flow ; several combined are still more 
certain to do so. It must, however, be admitted that very violent 
hemorrhages will sometimes take place from the non-pregnant uterus 
without our being able to determine their cause, none of the conditions 
just mentioned being recognizable. 

Causes. — The conditions which most frequently occasion menorrha- 
gia and metrorrhagia are — 

Menorrhagia. Metrorrhagia. 

General plethora ; Polypus ; 

Fungous degeneration of uterine Cancer or sarcoma : 

mucous membrane ; Retained products of conception ; 

Subinvolution ; Hematocele ; 

Fibrous tumors ; Acute pelvic cellulitis and perito- 

Chronic oophoritis ; nitis ; 

Retro-displacements of the uterus ; Lacerated cervix. 
Fecal impaction ; 

Hepatic, renal, and cardiac disease : 
Leucocythsemia and haemophilia. 

Menorrhagia. 

Greneral Plethora. — Full-blooded women Avho live well, do not take 
sufficient exercise, and perhaps even indulge more or less in alcoholic 
stimulants, are very liable to profuse menstruation. They are usually 
also habitually constipated, and their portal circulation is therefore not 
only overcrowded by the introduction of new matter, but not relieved 
by a regular evacuation of the bowels ; hence the pelvic organs are 
congested and uterine hyperemia exists, which is intensified at the 
time of the menstrual epoch. 

Fungous Degeneration of Uterine Mucous Membrane. — We have 
already discussed this subject in a separate chapter. It may be said 
to be one of the most frequent causes of profuse menstruation, usually 
as a result of chronic uterine congestion, commonly associated with 
catarrhal endometritis. The diagnosis is easily made by the curette, 
and the treatment carried out and cure effected by a more thorough 
employment of the same instrument. 

Subinvolution. — Following abortions and confinements at term, 
when the labor has been unusually rapid or unusually slow, a proper 
involution of the uterus very frequently does not take place ; the organ 
remains hyperaemic, enlarged, soft, and the blood-vessels are usually 
dilated. Hence when the menstrual congestion occurs a profuse flow is 
the result. When the subinvolution has gradually merged into its sec- 



METE ORRHA GIA . 609 

ond and chronic stage, generally known as hyperplasia, the profuse men- 
strual flow usually ceases, and even scanty menstruation may take its 
place. 

Fibrous Tumors. — The characteristic symptom of uterine fibroids 
of the interstitial and submucous variety is to induce an increase of the 
menstrual flow. Menstruation recurs regularly every four weeks, but 
may last nearly the whole intermenstrual period, the patient being free 
from discharge only for a week or less during the month. Intermen- 
strual discharges of blood do not usually occur unless the fibroid has 
become a polypus. 

Chronic Oophoritis. — In chronic inflammation of the ovaries, which 
really means a chronic congestion of those organs, the additional vascu- 
lar tension occurring physiologically at each menstrual period is liable 
to induce a hyperemia of the uterus which results in a profuse men- 
strual flow. This result is, however, not by any means invariable. 

Retro-displacements of the Uterus, if associated with congestion of 
the organ, are liable to provoke menorrhagia. Not infrequently, how- 
ever, a fungous degeneration of the endometrium exists in these cases. 

Fecal Impaction. — Aggravated degrees of this condition can 
undoubtedly, by obstructing the pelvic circulation, bring about such a 
condition of venous hyperemia in the pelvis as to excite a more than 
usually strong flow from the uterus at the menstrual period. While 
women are habitually constipated, it is but rare that such a degree of 
fecal impaction is observed ; still, the possibility of its occurrence should 
be borne in mind when seeking for an explanation of an apparently 
mysterious menorrhagia. 

Hepatic, Renal, and Cardiac Disease will, by interfering with the 
return of the venous blood to the heart, produce congestion of the veins 
of the whole body, and therefore also of the pelvis ; hence the tend- 
ency to menorrhagia. 

Leucocythcemia and Haemophilia. — In these diseases the number of 
white blood-corpuscles is so much greater than that of the red that the 
blood loses its normal property of ready coagulation, and any injury to 
blood-vessels is liable to be followed by a profuse hemorrhage. These 
diseases, fortunately, are not very common. They may be recognized 
by a careful inquiry into the previous history as to the tendency to 
hemorrhages from slight injuries, and by the discovery of an enlarged 
spleen, liver, or lymphatic glands. 

Metrorrhagia. 

Polypus. — A uterine fibroid which has become polypoid will inva- 
riably excite more or less copious discharges of blood from the uterus 
at irregular intervals — that is, both at. and between the menstrual 
periods. 

Cancer or Sarcoma. — The same applies to these diseases, since the 
profuse hemorrhages which they induce may occur at any moment, day 
or night, walking or sitting, without premonitory warning. 

Retained Products of Conception. — Hemorrhage from this source 
is most liable to occur very soon after the discharge of the first part of 



610 DISORDERS OF MENSTRUATION. 

the ovum, but it may take place at any time during a period varying 
from several hours to a number of weeks after the miscarriage. The 
history of the case should be carefully inquired into, and the statements 
of the patient as to the complete discharge of the ovum accepted with 
reservation until the examining finger satisfies itself, by finding the 
external os closed and the uterus normal in size, that its cavity is 
empty. Should the uterine canal be impassable for the finger, and 
still hemorrhage continue, dilatation by a tupelo tent and the use of the 
curette may show the presence of small fungoid growths at the placental 
site, which are probably the result of a subacute endometritis which 
has existed without any assignable cause. The removal of these 
growths with the curette will usually arrest the hemorrhage and cause 
the uterus to contract. 

Hematocele. — A bloody discharge from the uterus as a consequence 
of an effusion of blood into the pelvic cellular tissue or the pelvic peri- 
toneum is merely a sign of the general pelvic hyperemia which exists 
in such conditions. It may mean rupture of a tubal pregnancy, or the 
hematocele may be due only to rupture of some varicose vessels in the 
pelvic cavity. 

Acute Pelvic Cellulitis and Peritonitis. — The occurrence of a bloody 
discharge from the uterus during this disease is very common, and is 
merely an evidence of the general pelvic congestion natural to this con- 
dition. It appears an effort of nature to relieve the hyperemia, and is 
usually of no consequence. We can remember but one case where it 
was necessary for us to tampon the vagina in order to arrest the hemor- 
rhage accompanying acute pelvic inflammation. 

Lacerated Cervix. — If there is much eversion, erosion, and papillary 
hyperplasia of a lacerated cervix, a bloody discharge, sometimes quite 
profuse, is liable to occur at any time, especially after coition, digital 
examination, or, some special exertion. It is not usually very severe, 
and consists more in a so-called spotting than in an actual hemorrhage. 

Differentiation. — This is at once the most important and most diffi- 
cult of the physician's duties in reference to the symptoms which we 
are considering. If he be too easily persuaded to look upon the loss as 
one of the results of the ''change of life" or even of primary idio- 
pathic congestion, much time may be lost before his error is corrected. 
Should he forget that he is dealing with a symptom, and look upon the 
condition as a disease, he will often not merely lose time, but in the 
end entirely fail in giving relief; for the empirical practice of confining 
such patients to bed and relying upon astringents, cold applications, 
and narcotics will commonly be found to be ineffectual. In every case, 
unless the cause be palpable, it is advisable to examine systematically 
the entire uterus and its surrounding tissues in the following manner: 

1st. The cervix should be investigated by touch, the speculum, and 
the uterine probe. 

2d. The anterior and posterior walls and the fundus and sides of the 
uterus should be examined by conjoined manipulation, rectal touch, and 
palpation. 

3d. The whole pelvis should be explored by conjoined manipulation, 
rectal touch, and palpation. 



METRORRHA GIA . 611 

4th. The cervix should be dilated by tents, and the cavity of the 
body explored by the introduction of the index finger, by the uterine 
sound, and the curette. 

In many instances a diagnosis can be made only by these means, 
but by their aid, if fully developed, very few cases will baffle research. 

Tents offer us a most valuable means for diagnosis and treatment, 
but the practitioner must be very sure to open the os internum by them 
so that the finger may pass to the fundus. In many cases, Avhen it is 
supposed that a full investigation of the uterine cavity has been made, 
the os internum has never been passed by the finger, which conse- 
quently explores only the cervical canal. It will not infrequently 
require three and even four tents to open the cavity of the body fully 
to the finger. But such an exploration, although very thorough and 
satisfactory, is not free from danger. It may therefore be very gen- 
erally replaced by the passage of a loop of wire over the endometrium. 
If any small tumor exists, it will in this way be discovered, and if ute- 
rine fungosities exist, the removal of one or more will very surely dis- 
close the fact. 

Prognosis. — This will depend upon the cause of the affection. 
Should this be clearly ascertainable and curable, it will of course differ 
very much from what it would be if the cause were obscure and diffi- 
cult of removal. 

Results. — Menorrhagia and metrorrhagia, being but symptoms of 
the pathological conditions mentioned above, will produce results 
entirely in proportion to the nature, severity, and curability or incura- 
bility^of those conditions. Thus sterility, anaemia, general anasarca, 
extreme emaciation, hysteria, neurasthenia, and even death, may result 
in consequence of the profuse bloody discharge ; but we should always 
remember that this is merely a symptom, and that the true cause of 
the result is to be sought in the primary disease. 

Treatment. — This is either palliative or curative. If possible, the 
cause of the hemorrhage should be ascertained at once after seeing the 
patient. This should be done with the least possible delay, and only 
in cases where the life of the patient is not in immediate danger. The 
cause discovered (such as, for instance, retained product of conception, 
a fibroid polypus, fungous endometritis), it should be removed with the 
utmost despatch ; but if the necessary instruments should not be at 
hand for this purpose, or if the cause of the bleeding proves to be of a 
nature in which only palliative remedies can be applied, our first effort 
should be to stop the hemorrhage by the most thorough and convenient 
means at our disposal. In no case should we forget that it is the hem- 
orrhage for which we were called in, and which is the prominent symp- 
tom in the case, and that it is our first duty to stop it at any cost — if 
possible by removal of its cause, but, if that be impracticable at the 
time, by the most efficient means which we may happen to have at our 
command. We would therefore always recommend a rapid, careful, 
and thorough digital examination in order to elicit the cause of the 
bleeding, which if found should be at once removed if possible: but if 
not for some reason, we should endeavor to check the bleeding bv a 
systematic and efficient tamponade of the vagina, or if necessary even 



612 DISORDERS OF MENSTRUATION. 

of the uterine cavity, the very best agent for which is iodoform gauze, 
the advantage of which over the old tampons of cotton soaked in a 
solution of carbolic acid or covered with alum is that it acts equally 
well as a hemostatic, and can be left in place for several days without 
the slightest danger of its becoming offensive or septic. As it can be 
procured in any drug-store at a moment's notice, and should indeed be 
a part of the armamentarium of every general practitioner, not to men- 
tion the gynecological specialist, there never need be any delay in 
employing this method. The utero-vaginal tamponade is by all odds 
the most effective means of arresting a hemorrhage from those organs. 
In addition, an ice-bag should be put upon the abdomen, the patient 
kept scrupulously quiet, and hemostatics, such as fluid extract of ergot 
in fifteen-drop doses every two or three hours, fluid extract of hy- 
drastis canadensis thirty drops every three hours, or a mixture of 
tincture of digitalis and tincture of cannabis inclica ten drops of each 
every three hours (all of these pro re nata), should be given. In the 
milder cases of either menorrhagia or metrorrhagia it may not be neces- 
sary to resort to quite such vigorous measures ; especially does this 
apply to menorrhagia, where the administration of the internal remedies 
mentioned without the vaginal examination or tamponade may suffice. 
We would, however, call attention to the universal rule that in the 
absence of a physical examination of the parts from which the bleed- 
ing comes we are working in the dark, and may overlook the actual 
cause of the bleeding, and thus neglect to employ the only means of 
permanently arresting it. We have repeatedly met with cases of ute- 
rine polypi, of carcinoma of the cervix, and of fibroids of the body of 
the organ in which no symptom whatever was present from which we 
could hazard even a guess as to the true cause of the hemorrhage. 

Occasionallv. the source of the hemorrhage in metrorrhagia must be 
sought for through a speculum, in preference to or before making a dig- 
ital examination. For instance, in two cases of dangerous bleeding 
from ruptured hymen and vaginal wall, caused by first coition, only 
after inserting the Sims speculum and emptying the vagina of the 
coagula which filled it could we discover the location of the rent 
(P. F. M.). 

In cases of bleeding from a lacerated or cancerous cervix, local 
hemostasis by tampons covered with alum or persulphate of iron or 
tannin should be employed. It should be remembered that a tampon 
of tannin should not be placed upon a tampon saturated in a solution 
of persulphate of iron, since the combination of the two chemicals will 
result in the formation of ink — neither a useful nor an aesthetic agent 
in such a condition. 

For menorrhagia which does not depend upon any organic uterine 
disease, such as villous endometritis or fibroid tumors, the employment 
of ergot in combination with iron during the intermenstrual period acts 
very happily in controlling the bleeding, while at the same time sup- 
plying to the blood the metallic ingredient of which it is in need. To 
give iron alone in menorrhagia with the view of building up the gen- 
eral health of the patient seems theoretically perfectly proper, but prac- 
tically it results in increasing the amount of blood which will simply 



METE ORRHA GIA . 613 

be lost at the next period ; hence what the patient gains between the 
periods is sacrificed during the flow. By this combination of iron and 
ergot we believe that to a certain degree this drawback is avoided, the 
ero-ot seeming; to contract both the uterine and vascular tissues. 

Before assuming that a case of profuse menstruation is really one of 
true menorrhagia, the point must be considered that some women natu- 
rally menstruate very much more profusely than others, and that what 
to one would be an almost debilitating flow is to another merely a nor- 
mal menstrual discharge. If a woman informs us that she has during 
all her menstrual life used from two to five napkins a day during six 
or seven days, and we find her to be full-blooded, robust, and in every 
way healthy, w 7 e should not consider this otherwise decidedly profuse 
flow to be pathological. If, on the other hand, a small, slender, 
anaemic-looking woman should give us a similar history, we would be 
justified in assuming that she was losing a great deal more than nature 
intended she should, and that it was our duty to discover and remove 
the cause of the profuse flow. 

In cases of profuse menstruation which could not be controlled by 
the remedies, general and local, above mentioned, we have found it 
necessary to check the bleeding when w r e thought the woman had lost 
as much as she could spare by tamponing the vagina at each menstrual 
period for a number of months. Dr. Gehrung of St. Louis recently 
published an article advocating this practice ; but w y e had employed it 
independently long before the appearance of his article. This method 
should not be considered an interference with a natural function, since 
it is used only when that function oversteps the bound prescribed by 
nature. 

We have already referred to the fact that the persistence of a bloody 
flow T from the uterus at regular intervals of four weeks during pregnancy 
is to us a matter of considerable doubt. Irregular discharges of blood, 
how r ever — that is, metrorrhagia — to a more or less pronounced degree 
occur very frequently, and are usually due to some local lesion of the 
cervix or cervical canal, such as laceration, erosion, or cervical catarrh. 
Before proceeding to the local or general remedies above mentioned it 
would be well to assure ourselves of the existence or absence of preg- 
nancy in doubtful cases. 

Curative Treatment. — One great reason for the fact that this often 
proves fruitless is that the existing disorder, and not the disease which 
produces it, is kept before the mind of the practitioner. It should be 
borne in mind that the excessive hemorrhage is a symptom, and that 
the morbid state which creates it must be sought for and eradicated. 
We are confident that the statement already made, that one of four 
great pathological factors will usually be found to be the source of 
excessive or prolonged uterine hemorrhage, will stand the test of expe- 
rience at the bedside. We therefore place before the reader at a glance 
the ordinary causes of uterine congestion, solution of continuity, growths 
from uterine mucous surface, and blood dyscrasia. That there are other 
conditions, such as pelvic peritonitis, hematocele, etc., which may cause 
uterine hemorrhage, we do not deny; but when a bloody tiow marks 
the existence of such grave diseases, it is overshadowed bv them and 



614 



DISORDERS OF MENSTRUATION. 



Congestion 
due to 



of uterine tissue may be 



requires no special treatment. We here give those which ordinarily 
produce a flow which requires treatment from its prominence and 
importance, although Ave are almost repeating ourselves : 

Areolar hyperplasia ; 

Subinvolution ; 

Fibroids ; 

General plethora ; 

Displacement ; 

Fecal impaction ; 

Chronic ovaritis ; 

Laceration of the cervix. 

Ulceration ; 

Granular degeneration ; 

Cancer ; 

Sarcoma ; 

Laceration of the cervix. 

Polypi ; 

Fungous growths ; 

Adhering products of concep- 
tion ; 

Fibroids ; 

Sarcoma or cancer. 

Scorbutus ; 

Chlorosis ; 

Spangemia from uraemia or 
other grave constitutional 
disease. 



Solution of continuity may be created 

by 



Growths from uterine walls may con- 
sist in 



Blood dyscrasia may be due to 



If the source of the disorder be discovered, its treatment is often 
very simple and effectual, and as the management of most of the con- 
ditions here recorded is familiar to every reader upon general medicine 
or is given in other parts of this work, little more need be said except 
upon one or two points. 

In a case of subinvolution the free use of ergot will be found a val- 
uable adjuvant to the means already enumerated for palliative treat- 
ment, and it may prove serviceable as a curative agent. The same 
remark applies to the fluid extract of hydrastis canadensis, which may 
be well employed alternately with, or instead of, ergot. In the treat- 
ment of all uterine congestions the occasional use of an active purgative 
or the systematic and steady employment of the same class of medicines 
in small doses will often prove highly beneficial. 

Treatment of Fungous Degeneration of the Uterine Mucous Mem- 
brane. — If this condition be clearly diagnosticated, not surmised, but 
fully determined upon by rational and physical signs, the first consist- 
ing in prolonged hemorrhage, without the existence of other disease, 
and the second in evidence afforded by the detachment or expulsion of 
some of these masses, the whole lining membrane of the uterine body 
should be thoroughly but gently scraped by the curette represented in 
Fio\ 15G. 



I) YSMENORRHCEA . 615 

Should the cervical canal be narrow, it may he necessary to dilate it 
by a sea-tangle or tupelo tent ; but ordinarily no previous dilatation is 
necessary for the use of this instrument, which should be passed with 
a slight degree of scraping action over the entire surface of the uterine 

body. 

For a complete description of the use of the curette in uterine hem- 
orrhage and the necessary after-treatment we refer to the chapter on 
Uterine Fungosities. - 

In place of the curette the lining membrane of the uterine body may 
be modified by the application of pure nitric acid, after the plan of Kidd 
and Athill of Dublin, or by the injection of the uterine cavity by pure 
tincture of iodine, solution of nitrate of silver, or solution of persul- 
phate of iron diluted with two or three equivalents of water. As a full 
discussion as to the dangers of intra-uterine injections will be found 
elsewhere, we shall not enter upon the subject here. 

Should caustic treatment by strong acid be determined upon, the 
cervical canal and internal os should be well dilated, so as to prevent 
the acid from being wasted before it reaches the lining membrane of 
the body. 

In many cases replacement and support of a displaced uterus will 
serve to relieve a prolonged metrorrhagia, while the same results will be 
produced in others by cure of a granular and bleeding cervix or the 
repair of a lacerated one. 

All disorder of the blood should be combated by appropriate consti- 
tutional means, even where it is secondary to the loss and not a primary 
cause of it. Where the hemorrhage is due to a polypus, the resulting 
impoverishment of the blood renders escape of the vital fluid more easy 
and rapid. 

In very obstinate cases a change from a warm to a cold climate and 
from the lowlands to a mountainous region often accomplishes a great 
deal of good. 

Dysmenorrhoea. 

As already stated, normal physiological menstruation is unattended 
by pain or marked discomfort of any kind. A sensation of fulness in 
the pelvis, slight pain or aching in the back and loins, and a general feel- 
ing of irritability are the usual signs of approaching menstruation. But 
when any abnormal condition exists, either in the structures from which 
the blood pours into the uterus, in any of the surrounding parts or organs 
which undergo congestion during the menstrual epoch, or in the canal 
by which the blood passes into the vagina, menstruation may become 
exceedingly painful, and even undermine the health of the sufferer. 
This state receives the name of "dysmenorrhoea," a name derived from 
o^c, difficult, [Xfjv, a month, and fisco, I flow. 

Pathology. — Any condition, whether general or local, affecting the 
structure of the uterine Avails, the ovaries, or the surrounding areolar or 
serous tissues, so as to render the nerves supplying these parts morbidly 
sensitive, may produce pain in connection with the first part of the pro- 
cess. Anything impeding the escape of blood from the uterus or vagina 



616 DISORDERS OF MENSTRUATION. 

may produce it by interference with the second part. For example, a 
general condition resulting in neuralgia of the uterine or pelvic nerves, 
or a local inflammation altering their state, might readily create pain in 
the first stage, while either a natural or acquired stricture of the cervix 
would probably do so in the second. 

As a general rule, dvsmenorrhcea is due to one or more of the three 
following factors : 1st, a depreciated condition of the constitution, begin- 
ning usually either in the nervous system or blood, which creates a tend- 
ency to neuralgia ; 2d, an abnormal state of the uterus ; or 3d, a dis- 
eased state of the ovaries. In a woman in whom the nervous system, 
the uterus, and the ovaries are normal it is highly improbable that this 
condition would ever arise. Every practitioner can recall numerous 
instances in which any one of the three conditions mentioned had 
sufficed to establish it, and. as this is true of each of them separately, 
it is more so of a combination of the three. 

Every case should be examined from this standpoint in practice, and 
the treatment adopted should be governed by the discovery of the exist- 
ence of one or more of these conditions as causative agents. 

Varieties of Dysmenorrhea. — For convenience of study, dysmenor- 
rhcea may be divided into the following varieties : 
Neuralgic dysmenorrhea ; 
Congestive or inflammatory dvsmenorrhcea ; 
Obstructive dysmenorrhea ; 
Membranous " 

Ovarian " 

Seat of Pain in Dysmenorrhoea. — Upon this point our knowledge is 
not certain. It is probable that in the first three varieties the pain is 
seated in the uterus, in the ovaries, or in the cellular tissue or peritoneum 
surrounding the pelvic viscera. Some of the most intractable cases with 
which we have met have been due to pelvic peritonitis, which, even after 
inflammatory action has subsided, has left the nerves supplying these 
parts in so sensitive a state that pain, or even a recrudescence of inflam- 
mation styled menstrual pelvic peritonitis, is excited in them by the 
process of menstrual congestion. It is often very difficult to decide as 
to the exact seat of pain. Even a physical exploration instituted during 
the menstrual period may fail to enlighten us. 

The practitioner who regards dvsmenorrhcea as a disease, and applies 
to every case a uniform plan of treatment, will rarely meet with success 
in its management. He should view it as a symptom of an abnormal 
condition which should, as far as possible, be discovered and removed. 
Although, even when acting thus, cases will be met with in which he 
will be baffled, it will be gratifying to perceive how rarely these will 
occur. The great importance of differentiating the varieties mentioned 
and adopting appropriate plans of treatment calls for a separate study 
of each. 

Neuralgic Dysmenorrhea. — This variety depends upon no appre- 
ciable organic disorder of the uterus or its appendages, but merely upon 
a peculiar state of the nerves, which, under the stimulating influence of 
congestion, produces pain. 

Causes. — There are many agencies which at times so alter the healthy 



DYSMENORRHCEA. 617 

state of the nerves of the stomach as to produce in them, at each period 
of digestion, pain, which is called gastralgia or gastrodynia. Similar 
agencies may occasion neuralgia of the nerves of the eye or of those sup- 
plying the tissues of the head and face. In like manner they may affect 
the uterine nerves whenever these are inordinately excited from men- 
strual congestion. The same patient who from slight excitement or 
fatigue develops supraorbital neuralgia will often, from the same causes, 
suffer from neuralgic dysmenorrhcea. 

The causes which generally induce it are — 

The neuralgic diathesis ; 

Hysteria ; 

Chlorosis or plethora ; 

Certain blood-states, as those of malaria, gout, and rheumatism ; 

Luxurious and enervating habits ; 

Habits deteriorating the nervous systsm, as onanism or excessive 
venery. 
Symptoms. — Pain may show itself before the flow has been estab- 
lished, and disappear as soon as it comes on, or it may continue with 
varying intensity throughout the duration of the menstrual discharge. 
The patient usually complains of a sharp, fixed pain over the pelvis, 
down the loins, or in some distant part of the body. We once saw a 
patient who during each period suffered intensely from neuralgic pain 
on the outer side of one little finger, and another who before the flow 
was established experienced for several days a violent pain at the root 
of the nose. 

In some cases the pain seizes the patient very suddenly, and becomes 
so agonizing in character as to render her almost delirious. She will 
toss wildly upon her bed and give evidence of the most severe physical 
suffering. Then in a few hours the pain will almost as suddenly abate, 
and for the rest of the menstrual period exist only in very moderate 
degree. 

Differentiation. — When the pain is felt in the uterus it presents 
nothing expulsive in its character ; the flow of blood is steady and not 
interrupted ; no clots are discharged by spasmodic efforts ; and physical 
examination discovers no obstruction. These facts generally distinguish 
neuralgic from obstructive dysmenorrhcea, though sometimes differentia- 
tion is very difficult. 

From the congestive form it is differentiated by absence of constitu- 
tional disturbance and by its being habitual and not exceptional. It 
may be distinguished from the inflammatory variety by absence of the 
ordinary signs of endometritis and of ovarian and peri-uterine inflam- 
mation. There is also absence of leucorrhoea and pain, as well as of 
the physical signs of inflammation, in the intervals of menstruation. 

Prognosis. — If a patient affected by neuralgic dysmenorrhea be able 
and willing to effect a decided alteration in her mode of life, the pros- 
pect of recovery is good. Should no such change be attainable, it is 
decidedly unfavorable. 

Treatment. — The first duty of the physician should be to discover the 
cause of the development of neuralgia in the performance of the men- 
strual function, and the second to endeavor to remove this. Neuralgia 



618 DISORDERS OF MENSTRUATION. 

of the face and head is rarely a primary affection, and consequently resists 
remedies directed especially to it. It generally results from some focus 
of irritation — as. for example, a decayed tooth, or a plug of hard wax in 
the ear. or from some toxic element in the blood — and when the cause is 
removed it disappears. So with the disorder which we are considering. 
If the rheumatic or gouty diathesis exist, it should be treated by col- 
chicum. guaiac, and vapor baths. The skin should be kept warm and 
active by wearing flannel over the whole body in winter, and a mild, 
equable climate should be chosen during the cold months of the year. 
Should a delicate state of the nervous system have been engendered by 
habits of luxury, indolence, or dissipation, the patient should be sent to 
the country, where an out-of-door life, horseback exercise, early hours 
of retiring, and plain, wholesome food may exert a decidedly alterative 
influence. Chlorosis and plethora should be treated, the one by ferru- 
ginous and nervous tonics, fresh air. food, and cheerful surroundings ; 
the other by strict diet, venesection, cathartics, and other depletory 
means. Malarial toxaemia should be treated by change of residence, 
quinine, and iron. A sea-voyage will often accomplish an excellent 
result in neuralgic dysmenorrhcea by its alterative influence, whatever 
be the cause of the neuralgic state ; and the same may be said of surf- 
bathing. 

In addition to these general means, benefit may be obtained from 
the use of some which are local. The occasional passage to the fundus 
of the uterus of a uterine sound, the retention in utero of the galvanic 
pessary — which has been described when speaking of amenorrhcea — the 
use of tents, and the systematic employment of the continuous or gal- 
vanic current, one pole over the sacrum or against the cervix, and the 
other over the hypogastrium. will often prove very serviceable. 

Parturition often accomplishes an excellent result, and in many cases 
cures the affection entirely. 

Besides these means there are certain anti-neuralgic remedies which 
act more or less as specifics in this form of dysmenorrhcea. Foremost 
amongst these is apiol, a yellowish, oily substance obtained from the 
Petroselinum sativum by the action of alcohol and filtration with animal 
charcoal. It is in the form of capsules, each containing five drops. 
The dose of these is one capsule night and morning one week before 
and during menstruation. The mother tincture of pulsatilla. five drops 
in water three or four times a day. given during the week preceding 
menstruation only, has done excellent service in our hands in many of 
these cases. Antipyrine and phenacetin. in ten- to fifteen-grain doses, 
two or three times daily as required, also relieve the pain in this 
variety of dysmenorrhcea. The tincture of cannabis indica, in doses of 
twenty-five drops every four hours while pain is severe, is also beneficial, 
as is also the hydrate of chloral in ten-grain doses every eight hours. 
"Where a spasmodic element appears to exist in addition to the neur- 
algic, suppositories of butter of cacao, containing each a quarter of a 
grain of extract of belladonna, will often give great relief : they should 
not be repeated oftener than once in every eight hours. Under these 
circumstances, too. great benefit will often follow the use of enemata of 
tincture of asafcetida. two to three drachms in a gill of warm water. 



I) YSMENORRHCEA . 619 

or of ten-grain doses of chloral dissolved in half a pint of warm gruel. 
Placing the patient in a very warm general bath for from twenty to 
thirty minutes is likewise often productive of great relief. 

Congestive or Inflammatory Dysmenorrhea. — Definition. — 
At each menstrual epoch an active congestion occurs in the mucous 
membranes of the Fallopian tubes and uterus, as well as in the ovaries, 
and probably to a less degree in all the pelvic tissues. When any 
abnormal influence renders this excessive, it naturally produces pain in 
the nerves intervening between the distended vessels. This excessive 
hyperemia, which may result from a mechanical cause, as displacement 
of the uterus, or from a vital cause, as the peculiar condition which Ave 
know as inflammation, gives rise to a variety of painful menstruation 
which has been styled congestive or inflammatory. 

The state of inflammation which so alters the condition of the nerves 
immediately affected by ovulation or menstruation may exist in or 
around the uterus, in the peritoneum covering it, in the ligaments which 
sustain it, or in the areolar tissue of the pelvis. 

In a great many cases inflammation of the uterine mucous mem- 
brane is the cause of this form of dysmenorrhoea. The existence of 
disease in this part causes, perhaps, little pain until the erethism engen- 
dered by menstruation occurs. Then great local excitement takes place 
and dysmenorrhoea shows itself. 

Causes. — It may result from almost any pelvic inflammation or 
from any influence which exaggerates and prolongs the congestion 
excited by ovulation. Chief among these may be mentioned — 
General plethora ; 
Exposure to cold and moisture ; 
Sudden mental disturbance ; 
Sluggishness of portal circulation ; 
Displacement of the uterus ; 
Fibrous tumors ; 
Areolar hyperplasia ; 
Endometritis ; 
Pelvic cellulitis and peritonitis. 

Some of these causes, even without exciting true inflammation, may 
keep up a state of hyperemia in the uterine vessels, which, being aug- 
mented at menstrual epochs, creates pressure upon the neighboring 
nerves, and consequently pain. 

Symptoms. — A patient who has previously menstruated painlessly is 
seized during a period with severe pelvic pain, accompanied by diminu- 
tion or cessation of the discharge and considerable constitutional dis- 
turbance. The pulse becomes full and rapid, the skin hot and dry. 
and the eyes suffused. There is severe pain in the head, with nervous- 
ness, restlessness, and sometimes, though rarely, a little delirium. 
There may be in addition rectal and vesical tenesmus and diarrhoea. 
In cases in which a local inflammation exists as the flow begins or 
before that time, the patient suffers from dull, heavy, fixed pelvic pain, 
which lasts until the process is ended, and often even afterward. 

Differentiation. — If the attack be due to hyperemia merely, with- 
out inflammation, the constitutional disturbance and suddenness which 



620 DISORDERS OF MENSTRUATION. 

characterize it will mark its difference from the neuralgic and obstructive 
forms, as the absence of signs of inflammation in the intervals will do 
from the inflammatory. If it be due to the influence of existing pel- 
vic inflammation, it will usually be marked by pain during the inter- 
menstrual periods, difficult locomotion, fatigue after exertion, leucor- 
rhcea, etc. 

Prognosis. — This will depend upon the prognosis of the condition 
which has given rise to it. If that can be removed, the dvsmenorrhcea, 
which is one of its symptoms, will disappear ; if not, it will continue 
without material diminution. If the cause of the symptoms be a 
fibrous tumor, pelvic peritonitis, or peri-uterine cellulitis, or even an 
irremediable displacement, the probability of immediate relief is of 
course not at all great. 

Treatment. — As in the neuralgic variety, the source of the evil 
should be carefully ascertained before remedial measures are adopted. 
If it be due to plethora, the lancet, cathartics, strict diet, exercise, and 
fresh air will be indicated. Decided congestion of the uterus, as shown 
by turgid feel and purple appearance of the cervix, would indicate local 
abstraction of blood by scarification or leeches. Should the attack be 
accidental and have occurred from exposure to cold and moisture, 
opiates, diaphoretics, and sedatives will give speedy relief. In case a 
sluggishness of the portal circulation exists, this should be stimulated 
to greater energy by mercurial cathartics and a change in the habits of 
life from sedentary to active. A retro-displaced uterus is often kept 
in a constant state of congestion, which can be relieved only by prop- 
erly sustaining the organ. This, according to our experience, is a fre- 
quent cause for congestive dysmenorrhea. In many of these cases it 
will, upon recognition of the displacement, be scarcely credited by the 
practitioner that it is sufficient to be productive of the result. Yet 
replacement of the uterus and removal of superincumbent weight by 
means of a skirt supporter and abdominal pad will give such complete 
relief as to put all doubts at rest. If a fibrous tumor be the cause, a 
cure will depend upon its susceptibility of removal. 

Should any local inflammation be discovered as the cause of the evil, 
this, and not one of its many results, should be the subject of treat- 
ment. 

Obstructive Dysmenorrhea. — If, after the collection of blood in 
the uterus, any obstruction exist which prevents its escape into and 
through the vagina, a violent spasmodic pain is excited which often 
amounts to uterine tenesmus. To this form of painful menstruation 
the name of obstructive dysmenorrhcea has been applied. The obstruc- 
tion may exist in the os or cervix uteri, in the vagina, or at the vulva, 
where that canal is partially closed by the hymen. 

Pathology. — If any organ be filled with fluid beyond the point of 
tolerance — as, for example, the bladder, stomach, or large intestine — 
violent contractions of the distended fibres which make up its walls are 
excited, and spasmodic efforts which have received the name of tenes- 
mus are established. If evacuation result from these, relief is obtained : 
if not, contractions continue for a long time. When occurring in the 
uterus they present the symptoms which characterize the affection which 



DYSMENORRHEA. 621 

now engages us, and which are very similar to the expulsive pains 
occurring during normal labor. 

Causes. — The special causes of such obstruction are — 

Congenital or acquired contraction of the cervical canal ; 

Flexion or version of the uterus ; 

Vaginal stricture ; 

Small polypus in utero ; 

Obturator hymen ; 

A fibroid in the parenchyma of the neck. 
Any one of these causes may produce the result by partially occlud- 
ing the cervical canal, so as to allow of the escape of fluid imperfectly 
and painfully. Contraction of the cervix may be congenital, or may 
result from inflammation of the mucous lining of the canal, or diminu- 
tion of its calibre by contraction of the parenchyma from the use of 
strong caustics within the os or other cause. The last cause was for- 
merly a prolific one, the condition commonly resulting from the passage 
of the actual cautery, solid stick of nitrate of silver, or potassa cum 
calce into the canal of the cervix. Fortunately, at the present day 
these agents are but seldom employed, and hence this form of contrac- 
tion is now rarely met with. Flexion obstructs the canal by creating 
an angle in its course. Versions much more rarely produce the diffi- 
culty, but sometimes, the os being by reason of the displacement pressed 
very firmly against one wall of the vagina, a partial obstruction is pro- 
duced. 

[Some time ago a young girl presented herself at my clinique at the 
College of Physicians and Surgeons, declaring that at every menstrual 
epoch she suffered from the most intense bearing-down pains, which 
exhausted her greatly. Upon examination I found a partial closure of 
the vagina, the result of sloughing during typhus fever, which had pro- 
duced an accumulation of blood above it. This excited uterine con- 
traction, and each effort caused the expulsion of a small amount of the 
fluid collected above the stricture. — T. G. T.] In like manner the 
hymen may prevent free escape and produce uterine tenesmus. Obstruc- 
tive dysmenorrhea produced by this cause does not really come under 
the heading intended to be covered in this section, which, in common 
with the other forms of painful menstruation, treats only of dysmenor- 
rhoea produced by abnormal conditions of the uterus and appendages. 
For a full description of retention of menstrual blood from occlusion 
of the genital tract see the chapter on this subject. 

Sometimes a small polypus comes down to the os internum and rests 
upon it, obstructing the egress of fluid, but permitting the passage of 
a probe into the uterine body. It acts upon the principle of the ball 
valve, and by so doing produces the worst features of obstructive dys- 
menorrhea. 

Before closing the discussion of the causes of obstructive dysmenov- 
rhoea we should state that the occurrence of this variety of painful 
menstruation is denied by some authors, prominent among whom is 
Thomas Addis Emmet. He and those who agree with him claim that 
whenever menstrual blood can escape from a uterine canal, no matter 
how small or how tortuous or bent it is, there can be no such thing as 



622 DISORDERS OF MENSTRUATION. 

a mechanical obstruction to the exit of the blood. Besides, in such 
cases a probe or sound can often be introduced to the fundus without 
difficulty or great pain. They therefore claim that this variety does 
not exist, and they point to those cases in which menstruation occurs 
absolutely painlessly through a flexed, contracted uterine canal and 
pinhole external os. Undoubtedly this is true, but such occasions are 
certainly the exception, and those instances in which the conditions 
just mentioned are attended by severe expulsive pains until the more 
or less coagulated blood has been expelled are the rule. Besides, a 
uterine canal which may be perfectly patulous in the intermenstrual 
period, when the mucous membrane is undeveloped, becomes decidedly 
the reverse just before and at the beginning of the menstrual period, 
when physiologically the mucous membrane of the uterine cavity devel- 
ops to three or four times its normal diameter. So much is certain, 
that whenever coagula are expelled with contractile pains the blood 
must have accumulated within the cavity of the uterus for a sufficient 
length of time to cause it to excite efforts on the part of the organ to 
throw it off, and that such accumulation must be due to the absence of 
natural free drainage from the cavity. If this is not painful menstru- 
ation caused by an obstruction to the free discharge of the natural flow 
of blood, we are at a loss to know what to call it. 

• Symptoms. — After menstruation has continued for some hours, and 
sufficient blood has been collected in the uterus to distend it, a severe 
spasmodic pain occurs over the pelvis which has been styled " uterine 
colic." This rapidly passes into a violent expulsive effort like the con- 
tractions attending miscarriage, which in time causes the passage of a 
certain amount of blood. Then severe pain ceases for a time, until 
further distension and obstruction occur, when the process by which the 
uterus empties itself is repeated. 

It will be clear to the observer that the difficulty develops itself by 
three steps : 

1st. Some obstruction causes a collection of blood in the uterus : 
2d. This excites uterine contraction by distension ; 
3d. Uterine contraction, to a limited degree, frees the uterus and 
gives ease. 
This is the pathology of the condition, Avhether the obstruction exist 
in the vagina, at the vulva, or in the cervical canal. If it exist at the 
last point, the efforts of the uterus will generally expel a small clot, 
and then a gush of imprisoned blood will follow, much to the patient s 
relief. 

Differentiation. — The symptoms just related are so marked and 
decided that little difficulty will generally be experienced in determin- 
ing as to the pathology of the case. Before such a decision is arrived 
at, however, physical exploration will usually place the matter beyond 
a doubt. The absolute obstruction may generally be demonstrated by 
difficulty in the introduction of a probe into the cavity of the uterus. 
Should the obstruction exist in the vagina the finger will detect it, and 
if in the cervix the probe will do so with almost as great precision. 

It cannot be denied, however, that in exceptional cases a degree of 
constriction at the internal os which will admit the sound may, by some 



D YSMENORRHCEA . 6 2 3 

spasmodic action occurring at menstruation, offer an obstruction to escape 
of blood. Indeed, we feel that in all the varieties of dysmenorrhcea spasm 
of the fibres of the os internum plays a much more important rdle than 
is generally appreciated. It is this fact which explains the occurrence 
of severe pain at certain periods, while at others there is little or none. 
In some women there appears to be a regularity about this irregularity, 
the pain occurring without assignable reason every second month. 

Prognosis. — This will depend entirely upon our ability to overcome 
the mechanical obstacle. Should it not be possible to remove this, the 
constantly repeated distension of the uterine cavity, and consequent 
effort required for emptying it, will frequently result in endometritis. 
If uterine displacement exist, it should be treated by mechanical 
means ; any narrowing of the vagina should be overcome, and if pos- 
sible any obstructing neoplasm removed. If the indication in a given 
case can be completely fulfilled, the prognosis is good, but not other- 
wise. 

Treatment of Cervical Constriction. — Should it be discovered that 
the cause of difficulty consists in congenital or acquired constriction of 
the cervical canal, the condition may be remedied by two methods — 
dilatation and incision, the means for accomplishing which may be thus 
presented at a glance : 

Dilatation — 
By sounds ; 
By tents ; 
By expanding instruments. 

Incision. 

If the constriction be due, as it very commonly is, to flexion forward 
of the body or neck of the uterus, the point of stricture will usually be 
found near the os internum ; if it be due to congenital deformity with- 
out flexion, it will usually be found at the os externum ; while if an 
escharotic have created the difficulty, the entire length of the canal 
may be found deficient in calibre. 

Dilatation. — Sounds. — The dilatation of a constricted external 
and internal os and cervical canal by sounds has been practised for 
many years. To whom the credit for its introduction is due is perhaps 
difficult to say. One of the earliest practitioners to employ this method 
was Dr. Mackintosh of Edinburgh in 1832. He used graduated metal- 
lic rods. The late Dr. Kammerer of New York was an ardent advocate 
of this practice. Prof. Hegar has devised a series of very finely graded 
hard-rubber sounds, with which he claims to be able to dilate in a very 

Fig. 282. 




One of Hcgar's set of Graduated Sounds. 



short time and at one sitting any uterus to a size sufficient to admit the 
index finger. The late Dr. Peaslee and Dr. IT. T. Hanks of this city 



4 



624 



DISORDERS OF MENSTRUATION. 



have also devised sounds for this purpose. We have frequently prac- 
tised and more frequently attempted this method with variable suc- 
cess, and have finally abandoned it, for the reason that it often fails on 
account of the impossibility of forcing the larger sizes of the sounds 
through the canal, even under anaesthesia, and because we have a far 
more ready, convenient, and equally safe method at hand in the instru- 
ment known as the steel two- or three-branched dilator, presently to be 
described. The graduated sounds are highly recommended by Hegar, 
Fritsch, and other German gynecologists of repute. 

The expanding dilators have come into use chiefly since the intro- 
duction into this country of the dilator of Ellinger of Stuttgart, the 
first specimen of which was brought to this country by Munde. A 
number of improvements of this instrument have since been con- 



Fig. 283. 




Heavy. 
Palmer's Dilator. 

structed by Palmer, Goodell, and Elwood Wilson, all of which have 
two blades and dilate bilaterally. J. Marion Sims devised a dilator 
with three branches, which of course separated the uterine walls more 
thoroughly, but was at the same time rather more dangerous than the 
two-branched instruments. The dilator which we habitually employ, 

Fig. 284. 




Heavy. 

Goodell's Dilator. 



and which has answered every requirement that we saw fit to ask of it, 
is that of Palmer of Cincinnati. 



I) YSMENORRHOEA . 625 

Both the sounds and the expanding dilators may be used at the phy- 
sician's office, and we have thus employed them many hundreds of times 
without experiencing the slightest ill result. Still, there can be no 
doubt that the danger of exciting a pelvic peritonitis by this procedure 
is always present, and that a risk is taken in performing dilatation and 
sending the patient home which really should be avoided if possible. 
Not every patient, however, can afford to take an anaesthetic and keep 
in bed for a day or two simply for the purpose" of having her uterus 
stretched, and we therefore will probably still continue to perform dila- 
tation at the office under proper antiseptic precautions, sending the 
patient home as speedily as possible, and telling her to keep quiet for 
the rest of the day ; and, if our previous good luck does not forsake 
us, our patients will be benefited and no evil results will ensue. If 
very thorough dilatation, however, is to be employed, as in bad cases 
of constriction, or if discission is to be practised at the same time, or a 
stem pessary is to be inserted, and especially if the treatment is directed 
not only to the cure of the dysmenorrhea, but to the cure of the accom- 
panying sterility, it is best to do the operation thoroughly at the house 
of the patient under anaesthesia and all antiseptic precautions, followed 
by rest in bed, with an ice-bag on the abdomen, for twenty-four to 
forty-eight hours. If performed in this manner, more lasting benefit 
will probably result than if less thoroughly but more frequently prac- 
tised at the office. 

While moderate dilatation will often relieve temporarily, to secure 
permanent results it must usually be repeated a number of times, the 
most thorough dilatation being practised just before an expected period. 

Dilatation may be practised either on the fingers or through a spec- 
ulum, preferably, of course, the Sims, the branches of the dilator being 
separated so as to indicate on the cross-bar over the handles an internal 
dilatation of one-half an inch. Allowing for a small amount of feather- 
ing of the blades, this degree of dilatation is not excessive or. dan- 
gerous. 

Tents. — The sponge tent is no longer used by careful or progressive 
gynecologists ; the laminaria or the tupelo tents, however, are fairly 
safe if aseptically employed, and if left in situ eighteen to twenty-four 
hours produce a more lasting expansion than the rapid forcible dilators. 
As they should always be inserted at the house of the patient, who is 
kept in bed until and for some time after their removal, their use is 
attended with considerable inconvenience, and therefore restricted to 
the more serious cases requiring dilatation. 

Incision. — Prof. Simpson of Edinburgh was probably the first to 
advocate, in 1843, the practice of cutting through the walls of the cer- 
vix for the cure of dysmenorrhoea. He employed a closed knife, which 
was introduced through the internal os and then opened by a spring 
and withdrawn, the blade cutting to a desired depth through one side 
>of the uterine wall. It was then reintroduced and the operation 
repeated on the opposite side. Hemorrhage was stopped by brushing 
the surface with a solution of persulphate of iron. Greenhalgh, Stohl- 
mann, White, and others have invented complicated metrotomes or dou- 
ble-bladed hidden knives for the purpose of cutting through the con- 



626 DISORDERS OF MENSTRUATION. 

stricted part at one blow, but these instruments have the disadvantage 
of sometimes cutting deeper than is intended, and thus wounding either 
the peritoneum or a large vessel. They have, therefore, become more 
or less obsolete, most operators of the present day preferring to trust to 
their own sense of touch as to how deep the incision is made, rather 
than to hidden springs and complicated mechanisms. The simplest 
method of performing the operation of bilateral division — or discission, 
as it is called — of the uterine canal is that devised by Sims, several 
modifications of which have been introduced by various operators whose 
names have become attached to their modifications. 

Operation. — The method which we employ preferably is the follow- 
ing : With the patient in the Sims position, through a Sims speculum 
the cervix is exposed, a tenaculum hooked into the anterior lip of the 
external os, and if this orifice is abnormally small it is then incised in 
the following manner : A blunt-pointed bistoury or a pair of straight 
sharp scissors is used, and the cervix divided to the limit of a quarter 
of an inch in four directions — anteriorly, posteriorly, right, and left. 
Each of these little flaps thus formed is hooked up with a tenaculum 
and trimmed off with a pair of fine curved scissors. This makes a fun- 
nel-shaped external orifice. A sound or probe is then passed through 
the internal os, its diameter and the direction of the uterine canal care- 
fully ascertained, and if possible a straight blunt-pointed bistoury is 
passed through the internal os and the constricted portion divided quad- 
rilaterally to the depth of a sixteenth of an inch ; that is, until the cir- 
cular fibres are felt to yield under the knife. The probe-pointed knife 
shown in Fig. 204, devised by the late Dr. Studley of this city, is 
inserted and gently pushed forward until the blade passes through the 
internal os. It is then turned and the other three incisions made in 
the usual manner. It is now our practice, unless some contraindication 
(history of pelvic inflammation) is present, to introduce the Palmer 
dilator and thoroughly dilate the uterine canal. Having then washed 
out the vagina with a 1 : oOOO bichloride solution, with which also the 
uterine cavity is mopped out on an applicator, a thick glass or hard- 
rubber plug is passed up into the uterus and kept in place by tampons 
of iodoform gauze. If this is done, neither sepsis nor hemorrhage need 
be feared. Inflammation can be controlled by rest in bed and the ice- 
bag to the hypogastrium. After three or four days, or when the gauze 

has become saturated with the sero-sanguinolent oozing which in Van- 
es O 

ably follows this operation, it is removed and replaced, the stem being 
left undisturbed. If Ave do not fear hemorrhage, in place of the iodo- 
form gauze a Thomas cup pessary is inserted to keep the stem in place ; 
indeed, we use this more frequently than we do the gauze. The vagina 
is kept clean by daily irrigations with 2 per cent, carbolized water. 
After a week, if the patient experiences no pain and there are no bad 
symptoms of any kind, she may be allowed to leave her bed, wearing 
the stem constantly until the beginning of the next menstrual period, 
when the stem may either be removed, to be reintroduced at the cessa- 
tion of the period, or it may be left undisturbed. Some operators have 
had stems made with grooves along the sides or with perforations through 
the centre to permit the free escape of the menstrual blood. We have 




D YSMENORRHCEA . 627 

never seen the blood obstructed by the presence of the stem, but will 
admit that this may occur and that the blood may become septic, arid 
have therefore thought it best to remove the stem during the menstrual 
period. The individual preferences of p IG 2 85. 

different operators must be the guide as 
to which course to pursue. For the cure 
of obstructive dysmenorrhea it is usually 
not necessary that a stem should be worn 
longer than during two or three intermen- 
strual periods following the first opera- 
tion. For the cure of sterility, however, 
especially when the obstruction was due 
to an aggravated degree of anteflexion, 
the stem may have to be worn for a year 
or longer in order to ensure permanent 
straightening and patulousness of the 
uterine canal. Where only the external 
os is constricted the crucial incision 

(Fig. 285) alone need be practised, the Dysmenorrhea or Sterility. 

canal being kept open by frequent dilatations — that is, at least once a 
week — with the Palmer dilator. 

Treatment of Cases dependent upon Flexion or Version. — Should 
version be the cause of dysmenorrhcea, it should be relieved, not by 
operation, but by the means already mentioned when speaking of that 
displacement. If the difficulty be due to flexion, and more particularly 
to anteflexion, two indications offer themselves for its relief: First, to 
straighten the bent canal by keeping the body of the uterus erect ; 
second, to effect the same end by surgical operation. 

If a uterus be flexed below the vaginal junction, it is evident that 
obstruction to the menstrual flow will occur at the point of flexure, and 
equally evident that an incision through both sides of the canal would 
not overcome this by straightening it, while a single incision through the 
posterior wall would do so. In 1862, Dr. Sims conceived and practised 
such an operation successfully. The doubtful value of this procedure 
from a practical standpoint, in spite of its theoretical and anatomical 
correctness, has already been pointed out in the chapter on Anteflexion. 

Treatment of Vaginal Stricture. — This condition, which may be 
congenital or be induced by syphilitic or cancerous disease or by slough- 
ing, if so complete as entirely to obstruct the canal produces amenor- 
rhoea. If it be a pervious stricture it may result in dysmenorrhea. 

The affection may be treated by three methods : dilatation by large 
bougies, dilatation by tents, and incision. If syphilis be ascertained 
to be the basis of the local disorder, constitutional means should at the 
same time be resorted to. 

Treatment of Dysmenorrhea from Polypus. — Should the presence 
of a small polypus be discovered, the cervix should be dilated by tents 
and the growth removed. 

Treatment of Obturator Hymen and Fibroid*. — The first should he 
incised, and the second removed, if possible, by one o\' the methods 
mentioned under the head of Fibroids. 



628 DISORDERS OF MENSTRUATION. 

Membranous Dysmenorrhea. — Definition. — This variety of dys- 
menorrhoea consists in the expulsion of organized material from the 
uterine cavity at menstrual periods, which is found upon microscopical 
examination to consist of the lining membrane of the uterus itself. 
This may consist of a sac, representing the triangular cavity of the 
body of the uterus with its three openings, or it may come away piece- 
meal as shreds or strips of mucous membrane. 

Observers since the time of Morgagni have recognized this form of 
disordered menstruation, but looked upon the mould cast off as formed 
of false membrane, and as being a result of croupy or diphtheritic endo- 
metritis. For the true explanation of the phenomenon we are indebted 
to Simpson, Oldham, and Virchow. 

Pathology. — Dr. Oldham's opinion, which strikes us as the most 
rational, not only upon theoretical grounds, but from close observation 
of those cases which have come under our notice, is that at some time 
during the intermenstrual period the entire lining membrane of the 
uterus is lifted from its base and separated, so as to be ready for extru- 
sion at one of the next menstrual crises. Virchow declares that a 
deciduous membrane similar to that of pregnancy forms, and for this 
membrane he proposes the name of the "menstrual decidua." Dr. 

Oldham believed that congestion of the ovaries gave rise to this remark- 
is . . ^2 

able phenomenon by transmitting an irritant influence to the uterus. 
However inaugurated, this process appears to prepare the membrane 
gradually for complete detachment and extrusion at a menstrual period, 
when it is expelled. Simpson, denying the causative influence of inflam- 
mation in the production of the menstrual decidua, regards it as a 
product natural to the uterus as to function, but unnatural as to time, 
circumstances, and frequency of development. 

An entire membranous cast when washed and examined by the 
naked eye is found to be triangular, with three openings, two at its 
upper angles and one at its lower. Its external face is soft and irreg- 
ular, and everywhere shows small perforations, which are openings of 
utricular follicles. The inner face is free from inequalities and feels 
like mucous membrane. These sacs are usually extruded as they lie 
in utero, but sometimes they are inverted. In one instance we have 
known such a sac to become inverted and expelled into the vagina, 
but, the cervical extremity holding its attachment at the os internum, the 
inverted bag hung like a polypus in the vagina. A similar case is 
recorded by Mme. Boivin. 

Under the microscope the cast is found to consist of the lining mem- 
brane of the uterus, liypertrophied in all its elements almost exactly as 
it is in pregnancy. The vessels of the mucous membrane are increased 
in size, capacity, and number, a small-cell proliferation of intergland- 
ular tissue has taken place, and great development has occurred in the 
utricular glands, the mouths of which are visible even to the naked eye. 
The absence of the chorion villi and of the large, irregular decidua-cells 
of pregnancy easily distinguishes the membrane from the decidua of 
pregnancy. 

Etiology. — This part of our subject constitutes one of its most 
important and interesting points, but, unfortunately, that diversity 



DYSMENORRHEA. 629 

of opinion which always characterizes unsettled questions is found to 
exist here. Our want of accurate information depends upon the fact 
that the true pathology of the condition is not knoAvn. Some, with 
Oldham and Tilt, regard it as a result of ovarian disease ; others, with 
Kaciborski, Lebert, Handfield Jones, and Simpson, look upon it as a 
pure desquamation or exfoliation of the uterine mucous membrane, for 
which no cause can be assigned; while Klob and others are convinced 
that it is an exudation the result of endometritis, thus returning to the 
position assumed by our forefathers. In further reference to etiology 
we shall give a resume of the views which have been and are received, 
and mention some of the authorities who adhere to them : 

1. It was formerly believed that a layer of plastic lymph was, as a 
result of endometritis, thrown out over the uterine wall, which, becom- 
ing organized, constituted the cast of the uterus. This belief was 
entertained by Montgomery, Dewees, Siebold, Frank, Naegele, Desor- 
meaux, and others. 

2. It is now regarded as an exfoliation of the entire mucous mem- 
brane of the uterine body, due to congestion and irritation transmitted 
to the uterus. This view, conceived by Oldham, is adhered to by 
Semelaigne and others. 

3. The pathological explanation just mentioned being adopted, the 
cause of the occurrence of the exfoliation is attributed, in the words 
of Scanzoni, 1 to " a considerable hyperemia of the walls of the uterus, 
which is followed by an excess in the development of the mucous mem- 
brane." This theory is adopted by Courty, Hegar, Eigenbrodt, and 
others. The last two authorities have proposed for it the name of 
" dysmenorrhea apoplectica." 

4. Prof, Simpson 2 attributed the exfoliation "to an exaggeration 
of a normal condition or to an exalted degree of a physiological 
action." Mandl 3 declares that Rokitansky, Robin, Mayer, and others 
adopt this view. 

5. It is regarded as due to an inflammatory condition by Klob, 4 
who declares that "those pathologists were not far from the truth who 
described such cases as endometritis." This view is endorsed by Tilt, 5 
Braun, 6 and others. 

6. By some the membrane is regarded as due to a deciduous forma- 
tion excited by conception, which has just been established, or is ovular 
in its character. The first of these views is maintained by Hausman 7 
and admitted in some cases by Rokitansky; 8 and the second was 
advanced by Raciborski. 

From our observation of this affection we cannot attribute it to endo- 
metritis alone, for evidence of the existence of that disease was entirely 
wanting in four cases out of five. Even if endometritis exist with 
marked displacement, it must not be concluded that these conditions 
have necessarily produced exfoliation, for they are commonly present as 

I Op. tit, p. 348. ^ 2 Clin. Leet. on Dis. of Women. Am. ed., p. 109. 

3 Dr. Mandl of Vienna, translated in the Amer. Journ. of Obstet., vol. ii. p. 402. 
* Op. tit., p. 237. - s Lancet, 1853. 

6 Expression of opinion in Dr. Mandl's ease. See his article, p. 413. 

7 Mandl's article, p. 407. 8 Klob, op. ciV., p. 237. 



630 DISORDERS OF MENSTRUATION. 

results in cases in which dysmenorrkoea of membranous type lias lasted 
long without evidence of their existence. 

Recent observations have not added anything particularly new to 
the account of this disease given in our last edition. We have, there- 
fore, not thought it necessary to alter our description in any important 
detail, except with regard to the possibility of mistaking this condition 
for an abortion, which we at present know to be unlikely if the micro- 
scope is allowed to settle the question. 

Frequency. — We cannot regard the disease as one of frequent occur- 
rence, for in our experience we have met with it scarcely a dozen times. 
It is true that we have seen a number of cases which had been regarded 
as of this character, but most of them proved not to be so upon closer 
examination. Scanzoni reports twenty-one cases. 

Differentiation. — The diseases with which this may be confounded 
are — 

Early abortions ; 

Blood-casts, or fibrinous moulds of the uterus ; 
Exfoliation of the vaginal mucous membrane; 
Diphtheritic endometritis. 

From the first of these the differentiation can be accomplished by 
the progress of the case, the repetition of the process, and the entire 
absence of the symptoms of pregnancy. We have already stated that 
the absence of the characteristic villi of the chorion and of the large 
irregular decidua-cells of pregnancy definitely settles the question 
against that condition. This knowledge is an outcome of the improved 
microscopic observations of recent years. Before the publication of the 
last edition of this work this question was still in doubt, since two such 
authorities with the microscope as Rokitansky 1 and Wedl 2 of Vienna, 
quoted by Mandl (op. cit.), differed diametrically in their opinion of the 
nature of a specimen from the same patient, Wedl pronouncing it to be 
a portion of the decidua and chorion of an ovum in the first weeks of 
pregnancy, and Rokitansky claiming that the specimen merely showed 
a development of the mucous membrane in excess of its usual men- 
strual degree, and not connected with conception. Since membranous 
dysmenorrhcea may occur in the virgin, it is of some importance to be 
able to make this differential diagnosis with absolute certainty, and for- 
tunately at the present day this seems to be possible. 

Blood-casts will readily be recognized by the microscope. No ele- 
ments of uterine mucous membrane are discovered. 

The microscope too will readily show the nature of false membranous 
casts of the uterine body, and of exfoliations of the vagina due to what 
Dr. Tyler Smith has styled epithelial vaginitis or to contact with per- 
chloride or persulphate of iron. 

Symptoms. — With the commencement of the menstrual flow there 
are steady pains, which increase as this progresses until the}* become 
violent and expulsive like those of abortion. Under these the os grad- 
ually dilates and the membrane is forced out into the vagina. Then 
there is commonly a tendency to monorrhagia, which, however, soon 
disappears, and the patient has passed through the attack. For some 

1 Mandl, op. cit., p. 415. 2 Ibid., p. 416. 



D YSMENORRHCEA . 



631 



time after it has passed off there are symptoms of endometritis and 
purulent and sanguineo-purulent discharges. Sometimes, according to 
Hucliard and Labadie-Lagrave, who have written an excellent article 
upon this subject in the Archives generates for July, 1870, membran- 
ous dysmenorrhea becomes complicated by diphtheritic endometritis, 
which is engrafted upon an attack of endometritis set up by the affec- 
tion which we are considering. 

Pain occurring with the commencement of menstruation ends only 
with the discharge of the exfoliated membrane. This membrane, as 
has been already mentioned, is pathognomonic of the kind of dysmen- 

Fig. 286. 




Dysmenorrhoeal Membrane (Coste). 



orrhoea which exists, and serves to differentiate it clearly from all other 
varieties. The appearance of the membrane is represented in Fig. 
286. 

Prognosis. — The prognosis as to cure is extremely unfavorable, 
although cases not only of complete cure, but instances in which in 
advanced stages of the disease conception has occurred, have been 
reported by Siebold, 1 Tyler Smith, D'Outrepont, and others. Two 
such cases have come under our own observation. 

Treatment. — When the etiology and pathogenesis of a disease are 
unknown, it is astonishing to see how various, contradictory, and 
energetic treatment usually is. Deficiency of knowledge in these 
respects rarely results in an expectant plan of treatment. It commonly 
induces excessive vigor of interference. In the disease which we are now 
considering the actual cautery has been freely applied to the cervix, 
while solid nitrate of silver and other caustics have been carried up to 
the fundus. 

Uncertain as Ave are as to the pathology of the disorder, little can 
be said with any positiveness as to treatment. For relief of the violent 

1 Mandl, op. cit., p. 423. 



632 DISORDERS OF MENSTRUATION. 

pains which attend the attack nothing compares in quickness, certainty, 
and efficiency with the injection of morphia by the hypodermic syringe. 
If this use of the drug be not inadmissible on account of constitutional 
intolerance, it should be resorted to once in every eight or every twelve 
hours. Should there be any objection to its use, the pains of the attack 
should be quieted by inhalations of sulphuric ether, carried only to the 
point of producing quiescence of the nervous system, not sleep or 
unconsciousness. 

If uterine or ovarian disease be detected, it should be treated in 
accordance with general rules. If no such cause for the exfoliation be 
discovered, applications of alterative character may be made to the 
uterine mucous membrane, as tincture of iodine, chromic or carbolic 
acid, solution of nitrate of silver, or solution of persulphate of iron. Dr. 
Fordyce Barker reports very satisfactory results from passing into the 
cavity of the body an ointment containing from one to three grains of 
iodoform to the amount introduced. Should displacement exist, it 
should be relieved, upon the principle that if Ave cannot cure a dis- 
order, it is at least w T ise to relieve its most prominent complications 
and disagreeable symptoms. The meagreness of this advice as to the 
treatment of so distressing a malady is but too apparent, but there is 
no help for it, as it arises from an absolute want of knowledge as to 
more certain therapeutic resources. 

[In one case under my care I effected a cure by the following means : 
First, dilatation by sponge tents, which were inserted once a week during an 
intermenstrual period (the sponge tent was used in this case on account of 
its stimulating and alterative quality : I believe this to be the last case in 
which I used the sponge tent — namely, fifteen years ago) ; second, through 
removal of the diseased endometrium with the sharp curette, followed by 
swabbing of the uterine cavity with strong nitric acid. The latter was re- 
peated at intervals of a week three times. During the two menstrual periods 
intervening no membranes were cast off, owing to the destruction of the ute- 
rine mucous lining by the sponge tents, curette, and nitric acid. Intra-uterine 
galvanism with the negative pole, sponge on the abdomen, was then practised 
three times a week during another intermenstrual period, the current being 
as strong as the patient could bear. After the third menstrual period, which 
was free from membrane, a wedge was excised from each lateral surface of 
the cervix, with the view of reducing the size of the large, engorged uterus, 
and the edges united by silver sutures. From that date on the patient never 
had another attack of membranous dysmenorrhea. It may be objected that 
the cure was worse than the disease ; but as all authorities admit that this 
disease is usually incurable, and as the patient expressed herself perfectly 
satisfied with the result, I do not think that any fault can be found with the 
length or severity of the treatment. — P. F. M.j 

Ovarian Dysmenorrhea. — Definition. — In a number of cases, 
unfortunately by no means small, no depreciated condition of the ner- 
vous system will be found to account for habitual dysmenorrhcea, and 
the most careful exploration of the pelvis will fail to discover uterine 
or peri-uterine disorder. In such cases, if by conjoined manipulation 
the regions to the side of and behind the uterus be investigated, a 
globular, slightly-compressed mass, about the size of a large walnut or 



DYSMENORRHEA. 633 

small egg, will often be found in the cul-de-sac of Douglas or on one or 
both sides of the uterus, low down and in close proximity to it. If the 
patient be now placed in the left lateral position, and two fingers of 
the right hand be carried up the vagina, their palmar surfaces looking 
backward, the presence of these smooth and movable bodies will be 
still better ascertained. They are the ovaries, enlarged, congested, ten- 
der, and prolapsed. 

In some cases their disordered condition will be accompanied merely 
by dysmenorrhea, but in others it will be marked by hysteria, amenor- 
rhea alternating with menorrhagia, and even by true epilepsy. Whether 
epilepsy is in such cases due to the existing ovarian disease we are 
unprepared to state ; but we have occasionally seen it accompany it, 
and must confess our belief that it may sometimes be caused by it. 
This is the condition commonly styled chronic oophoritis, which consists 
in congestion as its first stage, and hyperplasia of tissue with excessive 
nervous hyperesthesia as its second. 

The cystic enlargement of a number of Graafian follicles, so-called 
hydrops folliculorum, does not produce either local pain or reflex mani- 
festations. Such ovaries may feel precisely like those enlarged by sub- 
acute or chronic congestion, but they are much less tender, and do not 
become reduced in size after the subsidence of the congestion, as is the 
case with the latter, nor do they yield to local treatment. 

Symptoms. — It would be difficult to make the diagnosis of this form 
of painful menstruation by rational signs alone. It should rest upon 
a union of rational and physical signs, but a suspicion as to the nature 
of the case would generally be formed from the former. The pain pre- 
cedes the bloody flow by several days, and diminishes as it is estab- 
lished. It is of a dull character, extends down the thighs, is peculiarly 
likely to be accompanied by nervous manifestations and to create 
depression of spirits. The breasts often sympathize, becoming painful 
and tender to the touch. 

One very curious phenomenon which now and then marks these 
cases is the occurrence of intermenstrual or " intermediate pain," as it 
has been styled by Dr. Priestly. At times this occurs with wonderful 
regularity on a given day. In one case in our experience it occurred 
on the ninth day after menstruation had ceased ; in another on the four- 
teenth ; and in a third it commenced one week after the menstrual act, 
and continued for five or six days. 

It must not be supposed that in every case in which the ovaries are 
discovered to be large, tender, and prolapsed dysmenorrhea will neces- 
sarily exist, or that they will always be found in this condition where 
there are other reasons for suspecting ovarian dysmenorrhea. The rule 
is as we have stated, but it is by no means without exceptions. 

Pathology. — It is possible that the process of ovulation in a diseased 
ovary may excite, through its extensive and decided nervous connec- 
tions, congestion and nervous hyperesthesia in the uterus, which would 
create disordered menstruation of the congestive or neuralgic type. 
Ordinarily, however, the pain seems to be in the diseased ovaries them- 
selves, and to depend upon the dehiscence of the follicles oi' De Graaf. 
This can be proven by touching these organs during the early periods 



634 DISORDERS OF MENSTRUATION. 

of menstruation, and is made evident in cases in which ovulation 
occurs without menstruation, in cases of atresia or absence of the 
uterus. 

Prognosis. — The prognosis of dysmenorrhea due to this cause is 
very bad. In a young girl in whom ovarian disorder has advanced 
only to congestion recovery may rapidly take place ; but in a woman 
farther advanced in life, and in whom chronic enlargement of the 
ovaries has occurred and become associated with great tenderness and 
prolapse, the prospects of cure are very unpromising. 

Treatment. — In such cases sterility is, we think, the rule. If utero- 
gestation should be inaugurated, the nine months of inactivity and 
repose secured by it to the ovaries is likely to be of great service. We 
have yet to meet with a case of chronic character in which we have 
effected a cure by purely medicinal means. By anodynes and nervines 
of course pain may be annihilated, but this is far from effecting a cure, 
and their use possesses the additional disadvantage of exposing the 
patient to the dangers of contracting a bad habit in reference to their 
future employment. 

All means calculated to soothe local irritation, to give tone to the 
nervous system, and to combat sanguineous excitement should be 
resorted to. Change of air and scene, a visit to the mineral springs 
and baths of Germany and France, and removal of all influences which 
severely or disagreeably tax either mind or body will often accomplish 
great good. Warm sitz-baths and warm and soothing vaginal injections 
should be employed, and complete rest in bed, or great quietude if the 
patient objects to bed, should be prescribed during menstrual periods 
and for three or four days after them. Internally, we know of no 
means which are so efficacious as the free use of the bromides of potas- 
sium and ammonium, commenced a week before the menstrual act and 
continued until its close. 

During menstruation, opiates, alcoholic stimulants, and anaesthetics 
should, as far as possible, be avoided. Their use will probably give 
relief, and as a consequence they will be resorted to once a month 
thereafter. The danger of such a course is apparent. In place of 
them the tincture of cannabis indica, hyoscyamus, and camphor, or 
five-grain doses of the monobromate of camphor, may be employed. 
In some cases we have known a rectal suppository of five grains of 
iodoform to give great relief. 

We are unwilling to convey the idea that even these means are pro- 
lific of good results in such cases. They are by no means so, and are 
merely offered as the best with which we are acquainted. Our own 
experience leads us to dread the application for relief of one of these 
obstinate and unsatisfactory cases. 

Before leaving this subject we must put the reader upon his guard 
in reference to the following point. In treating of the subject of dys- 
menorrhea we have accepted all the varieties which are generally 
indicated by authorities, because we believe that by their adoption a 
more thorough investigation of the subject is secured, and because 
experience leads us to think that a recollection of them at the bedside 
will aid the practitioner in classification and treatment. It must not, 



D YSMENOBBHCEA . 635 



however, be supposed that every case of dysmenorrhea will prove sus- 
ceptible of strict limitation to one of these varieties. Such an antici- 
pation will lead to disappointment and distrust of this classification. 
Many — indeed most — cases demonstrate the existence of more than one 
disturbing element. Thus, for example, retroversion occurring in a 
debilitated, weak, and nervous woman, whose blood is impoverished, 
might cause a dysmenorrhoea, due in part to mechanical obstruction, in 
part to neuralgia, in part to congestion, and perhaps even, to a certain 
extent, to a secondary endometritis. Too much must not be expected 
from any classification, and it must be borne in mind that one of the 
great ends in view in adopting this style of arrangement is the attain- 
ment of thoroughness of investigation and facility of remembrance. 

In view of the fact which we have just mentioned, it is well for the 
practitioner to have at his disposal some general plan of treatment which 
may be resorted to in cases not readily susceptible of classification. The 
following is one which we think will be found effectual : As soon as 
menstruation begins, or some hours before if its approach can be recog- 
nized, the patient should go to bed and apply warmth, by bottles of 
hot water, hot bricks wrapped in dry flannel, or, as is better, by bags 
of India-rubber filled with hot water, to the feet, abdomen, and sacrum 
alternately. She should then take by the rectum an enema composed 
as follows : 

1^. Tr. asafoetidse, 3ij ; 

Tr. belladonna, gtt. xx ; 

Tr. opii, gtt. x ; 

Aquae tepidae, .liiiss. — M. 

S. Throw the whole into the rectum and retain. 

If the patient have any decided objection to the use of an enema, 
the following prescription will be found very useful : 

1^. Chloral, hydrat., gij ; 

Potassii bromidi, jjij ; 

Morphiae sulphat., gr. iss ; 

Syrupi aurantii cort., ^iij. — M. 

S. A dessertspoonful in a wineglassful of sweetened water every 
four hours while in pain. 

The following suppository will sometimes prove useful in place of 
the enema : 

1^. Belladonna ext., gr. j ; 

Extr. opii aquos., gr. iij ; 

Asafcetidre gum., J5ss ; 

Butyr. cacao, q. s. 

M. et ft. supposit. No. yj. 
S. One by the bowel night and morning while suffering. 

We must again reiterate that one great care o\ f the physician in these 
cases should be to avoid creating in the patient a craving for opiates 



636 DISEASES OF THE OVARIES. 

and stimulants, which should never be administered except by direct 
prescription of the physician, renewed at each menstrual period in 
accordance with the amount of pain. 



CHAPTER XL I. 
DISEASES OF THE OVARIES 

History. — Ancient literature is singularly barren upon the subject 
of ovarian diseases. That the functions of these organs were known 
to early anatomists there is no doubt, for as early as 200 B. c. the ope- 
ration of castration of female animals is alluded to by Aristotle, and in 
the second century A. C. they were described by Galen under the name 
of •• testes muliebres." As to the influence exerted by them upon 
menstruation they were not informed, for they attributed that process, 
according to Aristotle, to a superfluity in the blood — an opinion which 
was entertained even by Hippocrates. The works <:»f Aerius make no 
mention whatever of ovarian disorders, and those of Paul of iEgina are 
equally silent. When it is borne in mind that the ovular theory of 
menstruation dates back for its origin to the labors of Xegrier. Gen- 
drin. Bisehoff. Pouchet. and others of our own time, and that the ope- 
ration of ovariotomy was never systematically performed before the 
year 1809, it will be appreciated how recently the profession even in 
modern times has fully grappled with the subject. 

During the past thirty years full amends have been made for this 
delay in progress, for in that time no portion of the field of gynecology 
has received more attention or been more thoroughly investigated than 
that which now engages us. Xot only have most of the diseased con- 
ditions of the ovaries been satisfactorily investigated, and the diagnosis 
of them reduced to a scientific system, but for the most frequent and 
important of them surgical means have been instituted with such suc- 
cess as to have given procedures of the most appalling character and 
undoubted dangers the position of legitimate and justifiable operations. 
The recent literature of ovarian pathology and surgery is now enriched 
by the contributions of so many capable observers that it is almost 
invidious to particularize the most prominent. 

These remarks apply not only to large tumors of the ovary, with 
which their removal by abdominal section has made us thoroughly 
familiar at the present day. but also, if to a somewhat lesser degree, to 
the minor diseases of that organ — namely, those of an inflammatory 
character. Our present improved means of diagnosis, chiefly by 
bimanual palpation, have taught us not only to detect in a large ma- 
jority of cases the normal ovaries, but also the comparatively trifling 
enlargement produced by acute and subacute inflammations and chronic- 
congestions of that organ. Of course an experienced touch is requisite 
for the recognition of the difference between a normal ovary and one 
slightly enlarged by the above-named conditions or by the presence of 



HISTORY. 



637 



a number of slightly distended Graafian follicles. We can remember 
very well how, twenty years ago, it was considered quite a feat of dia- 
gnosis to detect the normal ovary by bimanual palpation. [Prof. Leo- 
pold of Dresden and myself, who in 1871 were fellow-students in the 
General Hospital at Vienna, made a -special point of seeing in how 
many cases we could make this diagnosis, and were both surprised and 
pleased to find that it was by no means as difficult as was generally 
supposed. — P. F. M.] At that time our knowledge of the minor dis- 
eases of the ovary was gathered mostly from the post-mortem exami- 
nations, where that organ was found more or less enlarged by inflam- 
mation or slight cystic development or adherent from often unsuspected 
local peritonitis — conditions which had not been detected, or even 
thought of, during life. All this has now changed, for we can at 
present, in nearly every case where bimanual palpation is at all pos- 
sible, arrive at a very fair idea of the size and probable pathological 
state of an ovary which has undergone one of these minor forms of dis- 
ease. In this recognition we have been very much aided by the infor- 
mation obtained during laparotomies for the removal of ovaries and 
tubes thus affected. Of course the histological degeneration of the 
ovary must remain a mystery, or at best a matter of conjecture, until 
the organ has been removed and subjected to the crucial test of the 
microscope. Our knowledge of the minute diseases of the ovary and 
of the Fallopian tubes, as will be proved hereafter, is one of the greatest 
achievements made in the department of gynecology in recent years. 
Realizing the present state of our information on this subject, it is 
curious to note that Hennig not more than twenty-five years ago made 

Fig. 287. 




Gradual Formation of Graafian Follicles, first stage (Waldeyer and Leopold). 

(t, n } epithelium; b, b, earliest recognizable ova-cells already in the epithelial stratum; c, connective-tissue 
columns advancing into the epithelial stratum; d, <(, collections of cells in process of imbedding 
(invagination?); e, c, primary follicles surrounded by small connective-tissue cells; /. groups of epi- 
thelial cells (ova) already imbedded (invaginated), among which are individual larger cells (primordial 
ova) ; (j, corn-cells of His. 

the statement, judging from 100 post-mortem examinations made by 
him, that in 10 out of 100 cases the diseased state of the ovary "was or 
might have been recognized during life more frequently by rectal 



638 DISEASES OF THE OVARIES. 

exploration than by vaginal or abdominal. To-day we should expect 
to make the diagnosis during life, so far as macroscopical change- _ : . 
in 90 out of 100 cases. 

Anatomy of the Ova ies. — The ovaries are two follicular glands 
about the shape and size of small almonds, situated one on each side 
of the uterus. So dependent are they upon the position of the uterus 
em I surrounding viscera that they have really no fixed place. They 
are usually found in the lateral and posterior parts of the true pelvis. 




as 



Gradual Formation of Graafian Follicles - ■ o . stage Waldeyer and Leopold). 

a, epithelium : b, ovarian duct with free extremity: e. larger group of follicles with racemose arrange- 
ment: d. ovarian duct containing : .e and transverse section of ovarian ducts. 

about an inch from the uterus, and just below the point where the Fal- 
lopian tubes enter that organ, the left being in close proximity with the 

Fig. 28 



a — i 



I 

d C c 

Gradual Formation of Graafian Follicles, third stage. 
:.ielium; b, orifice of duct large] imordial ova; d, d. collections of ova. 

rectum. Each ovary is attached to the peritoneum, which connects it 
Avith adjacent structures, and is firmly united with the uterus by means 
of a fibrous cord arising from the horn of each side. 

The Fallopian tube of each side is connected with the ovary by one 



ANATOMY OF THE OVARIES. 
Fig. 290. 



639 




m 



Fig. 291. 



Gradual Formation of Graafian Follicles, fourth stage. (Fully-formed ovum in the follicle.) 
«, epithelium; b, large Graafian follicle, with duct-like process, d, and ovum, c; e, small duct-like follicle. 

fimbria, and acts at periods of ovulation as its excretory duct. The 
surface of the ovary is not covered by peritoneum, for, arrived at the 
circumference of these organs, this mem- 
brane loses its characteristic appearances, 
and the only trace of it which is discov- 
erable is a layer of basement epithelium. 
Around the circumference of the ovaries 
a cortical portion exists whose duty it is 
to generate the Graafian follicles. With- 
in this is a fibrous structure, composed 
of muscular fibres, cellular tissue, vessels, 
and nerves, which receives the name of 
stroma. Removed from the stroma and 
examined with care by the microscope, 
each of the Graafian vesicles is found to 
consist of a sac, called the- tunic, which 
is filled with fluid, the liquor folliculi, in 
which is contained the ovum or egg which 
is the female contribution to conception. 
It is now accepted as a fact by most 
physiologists, although still contested by some, that the periodical dis- 
charge of blood from the uterus which is called menstruation is merely 
a uterine symptom of the discharge of one of the ova from the ovary 
by rupture of a follicle. After the period of puberty has arrived one 
or more of the follicles of each ovary burst every month by the fol- 
lowing process : a congestion or hyperemia, occurring in the ovary for 
some reason beyond our comprehension, causes an excessive secretion 




Section of Ovary, showing corpus 
luteum three weeks after menstru- 
ation (after Palton). 



640 



DISEASES OF THE OVARIES. 



by the walls of the follicle, in which a miniature dropsy take.- place. 
This goes on to rupture, and escape of the liquor folliculi. blood, gran- 



Fig. 292. 




Corpus Luteum of the Fourth Month of 
Preenanev after DaltoD . 



Fig. 293. 




Corpus Luteum of Pregnancy at 
Term after Dal: 



ular cells lining the ovisac, and the ovum. The nerve-supply to both 
uterus and ovaries is excited by this process, and one of the result- of 



Fig. 294. 




3 Ovarii of Newborn Child | Beig i 

?uch excitement is contraction of the delicate mi 'Idle layer of uterine 



ANATOMY OF THE OVARIES. 041 

fibres which surround the network of minute vessels enveloping and 
penetrating the uterine structure. This throws the vascular apparatus 
into a state of erection. Great engorgement occurs on the surface of 
the uterine mucous membrane, and probably on that lining the Fallo- 
pian tubes ; they rupture and a flow of blood takes place. Three ele- 
ments are concerned in this discharge: 1st, ovarian irritation excited 
by ovulation and transmitted "to the nerves governing the muscles con- 
stituting the middle coat of uterine fibres ; 2d, erection of the uterine 
vascular system ; 3d, consequent rupture of the blood-vessels of the 
mucous membrane of the uterus and escape of blood. The ovisac being 
thus emptied, a clot of blood soon forms within it, then an hypertrophy 
of the cells lining it occurs, and the corpus luteum is formed. 

If the examiner hold up one of the broad ligaments between him- 
self and the light, a small plexus of white crooked tubes will be seen 
forming a cone, the apex of which is directed toward the hilus of the 
ovary. It measures about an inch in breadth, and consists of about 
twenty tubes which are filled with a clear fluid. This is the organ of 
Rosenmuller, which has recently been minutely described by Kobelt 
under the name of the parovarium, and is supposed by him to be an 
exaggeration of the Wolffian body. The exact location of the par- 
ovaria is this : they lie beneath the ovaries and between the ulti- 
mate folds of the peritoneum covering the fimbriated extremities of 
the Fallopian tubes, which have received the name of the alae ves- 
pertilionum. 

The ovaries are supplied with blood through the spermatic (or, 
rather, ovarian) arteries, which, upon arriving at the margin of the 
pelvis, pass inward between the layers of the broad ligaments, and 
thus reach their lower border. Their nervous supply is not exten- 
sive, and is derived from the renal plexus. 

The ovary presents its most perfect type in the young virgin, when its 
dimensions are greatest and its surface is undeformed by the numerous 
cicatrices which appear at a later period. The dimensions of this organ 
are greater than they are during early virgin life only during and for 
six weeks after the process of utero-gestation. Hennig, who has made 
a special and exceedingly minute study of this point, declares that preg- 
nancy increases the length, but not the breadth nor the thickness, of 
the organ. Utero-gestation, which leaves the uterus larger than it was 
before, has the contrary effect upon the ovaries, Avhich after its accom- 
plishment diminish in size, never again to attain their former dimen- 
sions while in a state of health. 

Varieties of Ovarian Disease. — Any one or all of the tissues 
which have been mentioned may be affected by disease, or the position 
of the ovary may be altered to such an extent as to constitute a morbid 
state. The folloAving table presents a list of the disorders of these 
glands which will now receive special attention : 
Absence ; 

Imperfect development : 
Atrophy : 
Inflammation : 
Neoplasms. 



G42 DISEASES OF THE OVARIES. 



Absence. 



One or both of the ovaries may be congenitally absent, but such a 
condition is very rare. When it does exist, it is generally only a part 
of a complete want of genital development, which is manifested not 
only by these organs, but by the parts making up the vulva, the vagina, 
and the uterus. When one ovary is absent, it is usually a case of 
absence of the same horn of the uterus, or uterus unicornis. Kiwisch 
declares that it has been most frequently observed in the bodies of 
newly-born infants who were not viable on account of complicated 
deformities. Where there is congenital absence of the ovaries the 
Avoman is generally small in stature, her figure undeveloped, as if the 
period of girlhood were abnormally prolonged, and the genital system 
imperfect, as already mentioned. In some cases the mind is very 
deficient, a condition bordering upon idiocy sometimes existing. In 
others this is not the case, but the patient suifers from depression of 
spirits and appears to lack vigor both of mind and body. Development 
into womanhood has never arrived for her, and she remains a child 
without the vivacity and cheerfulness of childhood. 

[This statement, however, does not always hold good. During the past 
year I have seen two cases — one of a girl of eighteen, the other of twenty 
years — in whom the general physical development found in a female of 
those ages was present without the slightest exception, barring the absence 
in the first case of the ovaries, so far as a careful vaginal and rectal bimanual 
examination could determine, and the presence of a rudimentary uterus ; 
and in the second case the entire absence of both ovaries and uterus, only a 
few crescentic fibrous strands representing the latter organ. But both girls 
were well-developed and perfect specimens of feminine physical beauty at 
that time of life. The external genital organs and vagina were natural in 
formation and size, and only the mammary glands were conspicuous by their 
absence. In neither of these cases had there ever been the least sign of a 
menstrual epoch. Treatment of course was out of the question. — P. F. M.] 

Although certainty can only be arrived at post-mortem, a diagno- 
sis may be made during life by a thorough examination with one or 
two fingers through the rectum, aided by the other hand on the abdomi- 
nal wall. Indeed, one of the greatest benefits which can accrue from 
a correct conclusion will consist in the avoidance of all efforts which, 
being vainly addressed to exciting the performance of the functions of 
the ovaries, deteriorate the state of the patient. Should the general 
condition of the patient, the undeveloped state of the vulva, vagina, 
and uterus, and the entire absence of the menstrual crisis combine as 
evidences of the condition, a diagnosis is admissible. 

Imperfect and Irregular Development. 

This condition, which consists in persistence of the foetal state of 
these organs after the period of puberty, when rapid development should 
have occurred, is by no means so rare as that just mentioned. It may 
exist on one side only, though it generally affects both. As in the 
case of absence of the ovaries, a certain conclusion is not easy, and as 



IMPERFECT AND IRREGULAR DEVELOPMENT. 643 

in that case also Ave drew a presumptive conclusion from want of devel- 
opment in the other organs of generation, absence of the usual signs of 
the menstrual crisis, and lack of general constitutional vigor and devel- 
opment. 

[As examples of cases susceptible of such an explanation, T record the 
histories of two with which I have recently met. The first is that of Miss 
F , referred to me by Dr. Rodenstein of New York. She is twenty- 
four years of age, and yet has the appearance of a girl of thirteen. Indeed, 
it is difficult to believe the statement that she is more than that age. The 
features, limbs, mode of expression, and general deportment are those of a 
child. She has never menstruated nor shown any evidences of a tendency 
to do so. Physical exploration shows the vulva in the state of early girl- 
hood, the mons veneris destitute of hair, the labia thin, and the vagina so 
small and narrow that the little finger only can be introduced, and that causes 
great suffering. The canal being short as well as narrow, the uterus can be 
touched, and is found like a little nut in the vagina, so light that its weight 
is scarcely perceptible. 

The second case is one which T saw with Prof. W. H. Thompson. The 
patient is eighteen years old, and has never menstruated. Previous to the 
treatment established by Dr. Thompson she suffered greatly from epileptic 
seizures, which have evidently impaired the force of her intellect, but during 
the two months before I saw her she had been free from them. The girl is 
slow in her movements, childish in manner, and stupid in replying to ques- 
tions. Upon physical exploration the vulva, vagina, and uterus arc found 
fully and perfectly developed, the latter giving by measurement with the 
uterine probe two and a half inches. Nothing can be elicited with reference 
to the ovaries by physical means, but the rational signs mentioned, together 
with the fact that all the appearances of girlhood are combined with entire 
absence of any apparent effort at ovulation, render the supposition that the 
ovaries are undeveloped or fetal highly probable. — T. G. T.] 

[Exceptions to these two cases occasionally occur. During the past 
winter I chanced to meet with an instance of complete amenorrhoea in a 
married woman twenty-four years of age. She had never had any signs 
of impending menstruation, but stated that she had frequent irregular 
attacks of epistaxis. She consulted me on account of the amenorrhoea and 
sterility. She was a perfectly formed, well-developed, handsome woman. 
and an examination revealed a vagina of normal length, but an infantile 
uterus and ovaries. There was no indication for active interference, since 
her general health was perfect. I advised the frequent local use of the 
faradic current as a stimulant to the uterus and ovaries, but promised no 
positive results. — P. F. M.] 

Sometimes cases will be met with in which masculine development, 
emansio mensium, and sterility will lead to a diagnosis of absence of 
the ovaries, but which will subsequently undergo a change and give all 
the evidences of the presence and efficiency of these organs. [One such 
case, which occurred in the practice of Dr. Metcalf and myself, is worthy 

of record. Mrs. B , a large, muscular, and handsome woman, had 

menstruated very irregularly and scantily for ten or fifteen years. 
Sometimes the menstrual discharge would be entirely absent for months ; 
then it would at long and irregular intervals show itself for a day. 
Her health was not affected by this in any way. She presented, how- 
ever, many sig-ns of masculinity: the voice was harsh, the breasts Hat, 



644 



DISEASES OF THE OVARIES. 



and the chin covered with a sparse beard. After having been married 
for years she became pregnant, and in due time bore a child, subse- 
quent to which she menstruated more regularly and plentifully, and has 
since borne two children. — T. Gr. T.] 

Treatment. — Should the ovaries be congenitally absent, it is evident 
that art can do nothing to remedy the evil. Should they exist in an 
undeveloped or foetal state, it is possible that by a proper stimulus 
applied to them by the most direct means in our power growth and 
maturity may be fostered, unless the condition be one of aggravated 
arrest of development. The means which are most likely to accom- 
plish this are — 

General tonics ; 

Uterine irritation ; 

Electricity ; 

Marriage. 
The sanguineous and nervous systems should both be brought into 
as perfect a state of health as possible by ferruginous and bitter tonics, 
fresh air, exercise, change of scene, and a general observance of the 
laws of hygiene. 

The most direct method for irritating the ovaries is through the ute- 

Fig. 295. 




Accessory Ovary (Beigel). 
K. 0., right ovary; K. T., right tube; S, accessory ligament; T, accessory ovary. 



rus, with which so close a sympathy exists. For this purpose tents may 
be occasionally resorted to — as often, for instance, as once or twice a 
month. This not only prepares the uterus for its part of the process 



IMPERFECT AND IRREGULAR DEVELOPMENT. 



045 



Fig. 296. 



of menstruation, but causes a hyperemia in the ovaries, which we know 
to be the physiological forerunner of •ovulation. 

Electricity (usually the faradic current) may be employed by placing 
one pole of a battery over the spine and one over the ovaries, or, more 
effectually, by carrying one pole, protected where it touches the vagina, 
to the cervix uteri, connecting this with a battery, and passing the other 
pole over the ovaries. An intra-uterine galvanic pessary may likewise 
answer a good purpose when worn steadily and persistently. 

The ovarian irritation and congestion incident to the marital act 
will sometimes excite ovulation — not at the moment of coition, as was 
formerly supposed, but remotely. 

Irregular Development. — A few instances are on record in which 
the ovary is either developed in a peculiar manner, so as to be divided 
into two more or less separate parts, or else a constriction of the organ 
has taken place by means of constricting cicatricial bands. Beigel was 
the first to call attention to a pathological condition of the ovary which 
he termed " accessory ovary." In 350 autopsies on female cadavers 
he found 8 times at the boundary-line of the peritoneum and the ovary 
one or more small excrescences varying from the size of a millet-seed 
to a cherry, which on dissection were found to consist of true ovarian 
structure. Winckel reports having found 
this anomaly 18 times in 500 dissections 
of the female genitals. Further, the ovary 
may be divided into two similar portions, 
practically appearing like two ovaries. 
(See Fig. 296.) The ovary may also be 
constricted, either congenitally or by cica- 
tricial bands, so as to have a deep dent 
about its middle. Winckel describes a case 
of partial constriction of the left ovary 
with cystic disease of the constricted por- 
tion. (See Figs. 297 and 298.) All the cases 
of this anomaly which have been reported 
up to the present time have been col- 
lected by Winckel, 1 as follows: 1. Grohe, 
three ovaries, two on left side ; 2. Klebs, 
two right ovaries ; 3. Sinety, one ovary 
with seven pedunculated appendages ; 4. 
Olshausen, constriction of left ovary from 
peritonitis ; 5. Winckel, two ovariotomies 
on same patient, two cysts at first operation, and another removed at the 
second, the latter tumor having been developed from the constricted 
portion of the right ovary; 6. Winkler, double cyst on one side, due 
to constricted double ovary ; 7. Hoegh, similar to No. 6 ; 8. Kocks, 
three ovaries removed by operation, the third in the left broad liga- 
ment: operation, hysterectomy for carcinoma of the cervix: 9. Man- 
giagalli, supernumerary ovary lav between right ovary and the uterus. 
10. Winckel, right and left ovary in normal position, supernumerary 
ovary situated in front of the uterus closely attached to the posterior 

1 Textbook, lor. cit. 




Division of Ovary (Winckel). 
A C, accessory ovaries. 



646 



DISEASES OF THE OVARIES. 



wall of the bladder. To this should be added 11. Munde, three ovari- 
otomies on same patient, two right and left by Prof. Kuester of Berlin, 
verified by letter from that gentleman ; the third by Munde for an 
intraligamentous dermoid cyst of the left side, which must have orig- 
inated either from a portion of the left ovary left behind or from a third 



Fig. 297 




Cystic Degeneration of a Constricted Portion of the Left Ovary (Winckel). 
T, left tube ; v, s, 0, left ovary ; r, r, right tube and ovary. 

ovary on that side. In addition, Munde has removed during the past 
winter, from an unmarried woman upon whom he operated for a dermoid 
cyst of the right ovary, the left ovary constricted and enlarged in the 
manner shown in the accompanying cut. 

It is evident that these abnormal developments of the ovary may 




Left Ovary Constricted (Munde). 

render it possible for an operator to apparently remove both ovaries, 
either for tumors or for minor disease of the organ, and to leave behind 
by accident a third accessory ovary, which may keep up the functions 
of ovulation and menstruation, and, if by some chance the Fallopian 
tube of the respective side should be left permeable, also permit the 
patient to conceive. 



ATROPHY OF THE OVARIES. 



647 



Atrophy of the Ovaries. 

At a period varying from the forty-fifth to the fiftieth year the ova- 
ries are destined to undergo atrophy. They diminish in volume, become 
wrinkled, the Graafian follicles disappear, and the stroma becomes dense 
and non-vascular. This is a physiological process, and marks what is 
termed the menopause or period of menstrual cessation. Sometimes 
this process sets in at a very early period, owing to some abnormal 
condition which has excited it, and produces the same results as those 
following it when it takes place at the normal time. 



Fig. 299. 




Senile Atrophy of Ovaries and Uterus— Double Hydro-salpinx (Beigel). 

ET, right tube; RO, right ovary ; LT, left tube; LO, left ovary; VP, vaginal portion of cervix ; 

X, mucous polypus. 

Causes. — With regard to the special causes of this occurrence very 
little is absolutely known, further than the fact that it sometimes occurs 
from pelvic inflammations. It is probable that acute oophoritis may pro- 
duce it, and it is certain that at times it results from pelvic peritonitis. 

[The following case, which presented itself at my clinique some time ago, 

is illustrative of this fact : Mary G , a healthy young Irishwoman, aged 

twenty-four years, stated that she had a miscarriage at the third menstrual 
period, five years before, in Albany. Three days after the product of con- 
ception had been cast off" she was taken with a chill, with violent pain over 
the abdomen, and was declared by her physician to have inflammation of 
the bowels. Of this attack she nearly died, but after a confinement to bed 
for six weeks grew better. For two years after this she had irregular, pain- 
ful, and profuse menstruation. As she expressed it, whenever she became 
fatigued or excited flooding would come on. After this time the menstrual 
periods disappeared, and she now applied for relief on account o? amenor- 
rhoea of three years' standing. Physical exploration revealed the uterus in 
normal position, though diminished in size to about two inches. Nothing 
could be ascertained about the ovaries. 

The view which T took of the case was that pelvic peritonitis and acute 
oophoritis originally existed ; these left the parts in such a state that for two 



648 DISEASES OF THE OVARIES. 

years metrorrhagia and menorrhagia occurred ; then, subsequent contraction 
occurring in the effused lymph in and around the ovaries, atrophy resulted 
with its usual consequence, amenorrhoea. — T. G. T.] 

Other diseases besides pelvic peritonitis may produce atrophy of the 
ovary ; thus, typhoid fever, scarlatina, variola, are occasionally followed 
by a shrinking and a cessation of the physiological function of the 
organ. 

[I have had under my care a case of a single lady, forty-one years of 
age, who having regularly menstruated up to her nineteenth year, was seized 
with an attack of typhoid fever, after which she never experienced the 
slightest sign of menstrual molimen or flow. The physical examination 
revealed atrophied ovaries and a small senile uterus. She consulted me for 
a sciatic neuralgia which she supposed might depend upon some diseased 
pelvic condition. Treatment proved ineffectual. — P. F. M.] 

The peculiarly destructive influence exerted upon the ovaries by 
pelvic peritonitis will be impressed upon any one who makes an autopsy 
in a patient who has died of that affection, or who reads the reports of 
others. Very often the ovaries cannot be discovered in the mass of 
"putrilage" which occupies their site. 

Treatment. — An attempt may be made, by the means recommended 
in the treatment of undeveloped ovaries, to excite ovulation in any part 
of the glands which may still be capable of performing the function. 
But it should not be persisted in if not at once attended by good 
results, for inflammatory action may be excited by it. When these 
means are essayed great caution should be observed and their influence 
developed only to a limited degree. Benefit from treatment can be 
expected only when menstrual molimina recur with more or less regu- 
larity. In their absence it is absolutely useless to endeavor to excite 
the ovaries to increased growth or renewed function. 



Apoplexy or Hematoma of the Ovary. 

Definition. — Apoplexy of the ovary consists in a rapid effusion into 
its tissue of blood, which results from rupture of one or more of its 
larger vessels. 

The ovaries present the only example in the animal economy of apo- 
plexy occurring as a physiological act. At each menstrual period, as 
an ovule leaves its nidus, an apoplexy from the vessels of the tunic of 
the ovisac occurs as a necessary consequence. It is this which, upon 
subsequent alteration, constitutes the corpus luteum. Generally these 
hemorrhages are self-limiting and their effects rapidly disappear ; in 
some cases, however, the bleeding continues too long or returns after 
cessation, and then the collection of blood sometimes reaches the size 
of a man's fist or of a child's head. 1 In some instances the tunica 
albuginea of the ovary is completely ruptured, when the effused blood 
pours into the most dependent portion of the pelvic cavity, constituting 
pelvic hematocele. 

Sometimes after one severe hemorrhage, but usually in consequence 

1 Kiwisch, op. cit., p. 232. 



APOPLEXY OR HEMATOMA OF THE OVARY. 649 

of the recurrence at more or less distant intervals of a number of effu- 
sions of blood, the stroma of the ovary becomes entirely destroyed, and 
is replaced by one sac containing the effused blood. These recurrent 
hemorrhages excite an inflammatory reaction in the neighborhood of 
the ovaries, and adhesion of the organ to the adjacent surface of Doug- 
las's pouch takes place. These adhesions are a fortunate provision of 
nature, since they tend to prevent the rupture of the hemorrhagic sac 
into the peritoneal cavity. Each recurrent menstrual period produces 
an increase of blood in the sac, and perhaps also a new inflammatory 
reaction in its surroundings. While the primary effusion of blood. 
often only of small amount and confined to one or two Graafian fol- 
licles, is called apoplexy of the ovary, the destruction of the whole 
organ by recurrent extravasations of blood into its substance is known 
as hematoma of the ovary. The blood is usually thin, dark, and mixed 
with small black coagula. This condition may go on for a variable 
length of time, rupture seldom taking place. 

Symptoms. — The occurrence of apoplexy is often ascertained only 
in autopsy, no signs existing during life by which it can be positively 
diagnosticated. The symptoms which will usually point to its exist- 
ence are sudden and violent pain over the region of one ovary, with 
sense of great exhaustion, nausea, and vomiting. These symptoms, if 
combined with enlargement and tenderness of one ovary, as ascertained 
by conjoined manipulation, will be sufficient to render a diagnosis war- 
rantable if the patient's health has previously been good. 

Diagnosis. — If the hemorrhagic sac is so distended by its contents 
as to be tense, the diagnosis of a small ovarian cyst bound down by 
adhesions may be made by conjoined manipulation; the nature of its 
contents can, however, be ascertained only by means of vaginal aspira- 
tion. Should they prove to be dark bloody fluid, the diagnosis of an 
ovarian hematoma is usually correct. It might be the Fallopian tube 
containing blood, it is true, but the oblong shape of the tube as com- 
pared with the more spherical circumference of the ovary will usually 
enable us to differentiate between the two. 

[In three cases, one a lady from Montana, another from Vermont, and the 
third from New York, I was absolutely unable to detect by repeated careful 
bimanual examination any enlargement or disease of either ovary or tube. 
The patients' constant complaints of pain and persistent demand for an ope- 
ration and relief from the pain finally induced me to comply with their re- 
quests. On opening the abdominal cavity I found in all three cases that the 
ovaries were enlarged to about the size of an orange, with flaccid walls and 
universally adherent. On peeling the sacs out with the fingers, they burst. 
and the thin dark grumous blood which they contained escaped, at once 
clearing up the diagnosis. Both sacs were removed, the pedicles ligated, 
the abdominal cavity washed out with tepid sterilized water, and closed 
without drainage. All three patients made good recoveries. The difficulty 
in detecting the ovarian sacs was readily explained by the fact that their 
walls were lax and flaccid, and could no more be felt by the palpating fin- 
gers than can the coils of the small intestine. — P. F, M.] 

Prognosis. — The effusion of a small amount of blood into a Graaf- 
ian follicle, also productive of considerable pain at the time, is a mat- 



650 DISEASES OF THE OVARIES. 

ter of no serious consequence, since a blood-clot forms and may be 
absorbed or become organized; but if the ovary is more or less 
destroyed by the effusion of a larger quantity of blood into its stroma, 
the pain experienced by the patient is not only severe and more or less 
constant, but, as already stated, localized peritonitis is liable to occur 
and to return ; and later on possible rupture of the distended ovary, 
either into the peritoneal cavity, or, if it happens to develop in that 
direction, between the layers of the broad ligaments, may take place. In 
the former case an acute peritonitis may be excited which may termi- 
nate in death, or a pelvic hematocele may be formed, the effused blood 
being shut off from the peritoneal cavity by intestinal adhesions. If 
the hematoma ruptures between the layers of the broad ligament a pel- 
vic hematoma is formed, which, if the amount is sufficient, may bulge 
down into the vagina and produce pain and serious discomfort by its 
pressure on the neighboring organs. It is fair to say that rupture of 
this kind, either upward or downward, occurs with comparative rarity, 
such effusion being usually due to rupture of the distended Fallopian 
tube — a subject to be discussed hereafter. If rupture does not take 
place and the diagnosis of incurable ovarian disease is made, the 
removal of the offending organs ensures the only means of a restora- 
tion of the patient to perfect health. 

Treatment. — The symptoms of ovarian apoplexy or hematoma are 
so vague that no definite treatment can be recommended to arrest the 
effusion of blood in the early stages. Of course, rest in bed, ice-bag 
to the abdomen, administration of morphine to allay pain, are the 
means to be adopted on general principles, and are applicable to any 
case of severe pelvic pain or any other condition simulating an attack 
of pelvic peritonitis. "Should peritonitis actually occur, the treatment 
adapted to this condition should be employed, which will, in the first 
stages, be substantially that just mentioned. The removal of the dis- 
eased organs by laparotomy is the only means of curing this condition 
in its advanced stages. 



Displacement of the Ovaries. 

The extreme mobility of these glands and the laxity of their supports 
have already been remarked upon. Any influence which increases their 
weight, draws upon them directly, or acts upon them by traction through 
a neighboring organ may cause them to leave their position, and even 
in rare cases to pass out of the pelvis in the form .of hernia. For 
example, they may be displaced by inflammation, hypertrophy, cystic 
degeneration, etc., which cause increase of weight ; or they may be acted 
upon by contractions of effused lymph, resulting from pelvic peritonitis; 
contraction of the ovarian ligaments, etc., drawing them out of place ; 
or they may be affected by displacement of the uterus, pregnancy, or 
hernia of any of the abdominal viscera acting upon them by means of 
traction. A hernia of the ovary alone is very rare ; it is almost always 
attended by hernia of the Fallopian tube or some portion of the intes- 
tines or omentum. 

The most common cause of backward displacement of the ovaries is 



DISPLACEMENT OF THE OVARIES. 651 

retroversion or retroflexion of the uterus. Next are enlargement of the 
ovaries in consequence of congestion, inflammatory hypertrophy, and 
diffuse cystic degeneration. The ovaries are usually displaced into 
Douglas's pouch, the left one being commonly felt most readily, because 
naturally, as first pointed out by Barnes, the left pocket of Douglas's 
pouch is deeper than the right. Besides, for some reason or other not 
yet fully explained, the left ovary is more frequently congested, inflamed, 
and prolapsed than the right. Thus, Munde found that of 77 cases 
where either one or both ovaries were dislocated, the right was displaced 
19 times, the left 46 times, both together 12 times. In 60 of these 77 
cases the prolapsed ovary was enlarged ; in 44 cases the uterus was also 
displaced: retroverted 22, retroflexed 11, anteflexed 5, anteverted 1. 
descensus 5. In all but 2 cases the ovaries were prolapsed posteriorly, 
in 2 anteriorly, both the left ovary and both enlarged. 1 Displacement 
of the ovaries is said to be occasionally congenital. 

The ovaries may be prolapsed also into the inguinal canals, being 
usually then accompanied by the Fallopian tubes and in a few rare 
instances by the uterus itself. This condition, if confined to the ovary 
alone, is called hernia of the ovary, and manifests itself chiefly by the 
regular monthly recurrence of intumescence of the hernia. This, indeed, 
is the chief point of diagnosis. The ovary has also been known to be 
prolapsed through the femoral, umbilical, and ischiatic openings, or to 
form a part of a ventral hernia ; and Eiwisch has reported a case in 
which one ovary entered the foramen ovale. 

Symptoms. — The symptoms of prolapse of the ovaries vary accord- 
ing to the position of the prolapsed organ, the cause which has induced 
the displacement, and the possibility of its return to its normal position. 
Ovaries prolapsed behind the uterus into Douglas's pouch manifest 
themselves by more or less severe or constant pain in the lower part of 
the back, usually referred to the sacral or rectal region and intensified 
by the passage of hardened feces. There is further a sensation of 
dragging and bearing down, which is much more severe than is com- 
plained of when simple backward displacement of the uterus exists. 
Besides, dyspareunia or painful coition is complained of, and reflex gas- 
tric and other nervous disturbances form a part of the symptoms. If 
the prolapsed ovary is adherent to the bottom of Douglas's pouch, these 
symptoms are usually aggravated. A persistent symptom is a pain felt 
in the ischio-rectal fossa and hip of the affected side, often extending 
down the leg of the same side. 

Diagnosis. — The diagnosis is easily made by vaginal examination, 
the prolapsed ovary being readily reached by one finger in the vagina. 
The experienced touch can mistake it for nothing else, since scybala 
in the rectum are not tender, very freely movable, and usually more 
than two in number. Besides, the peculiar sensation of faintness and 
nausea produced by pressure on the normal ovary will aid the examiner 
in his diagnosis. 

Treatment. — The treatment consists in replacing the ovary, if it is 
movable, by digital manipulation or posture — that is. with the patient 
in the knee-chest position — and preventing it from re-entering the pel- 

1 Munde, "Prolapse of the Ovary;' American Gynecological Transactions, 1879. 



652 DISEASES OF THE OVARIES. 

vie cavity by a suitable pessary (one with a large post-cervical bulb is 
to be preferred) or by astringent tampons packed behind the cervix. 
If a retro- displacement of the uterus exists, the reposition of that 
organ, together with the ovaries, and its retention by a suitable pessary, 
will usually suffice to keep the ovaries in their normal position. If the 
ovaries are adherent, however, very little can be done except to reduce 
congestion and relieve pain by iodine and glycerin applications to the 
posterior vaginal vault. Their detachment and reposition is usually 
impossible except by means of a laparotomy, which would be indicated 
only under circumstances, such as pain and recurrent attacks of perito- 
nitis, the particulars of which will be described hereafter. In hernia 
of the ovary, if reposition fails, nothing but extirpation of the pro- 
lapsed organ will effect a cure. 

Oophoritis. 

Definition. — By this term is meant an inflammation of the tissues 
of the ovary — namely, those composing the stroma of the organ, the 
fibrous and cellular tissue, blood-vessels, and nerves. Inflammation of 
the Graafian follicles is seldom met with. Formerly some doubt existed 
as to the exact character of this disease, but microscopical investiga- 
tions have in recent years settled the question, and left no doubt that 
such a disease as inflammation of the ovary actually exists. 

Varieties. — Oophoritis may be either puerperal or non-puerperal. 
The first does not concern our present investigation, and we put it out 
of consideration. The non-puerperal form of the disease has been 
divided into acute and chronic, which will now engage us in order. 

Acute Oophoritis. — Acute inflammation of the ovary was formerly 
supposed to be a very rare affection except as the immediate result of 
parturition. The older authors state that they do not remember ever 
having seen an uncomplicated case (Boivin, West, Fordyce Barker). 
At the present day, however, we are assured that this affection does 
occur much more frequently in the non-puerperal state than was for- 
merly supposed, and we now know that one of the chief factors in the 
production of this acute inflammation of the ovary is acute inflamma- 
tion of the Fallopian tube, which spreads directly by contact or indi- 
rectly through the peritoneal membrane enveloping both organs from 
the tube to the ovary. Puerperal oophoritis, it is true, is usually very 
much more acute and violent in its symptoms, and more frequently 
leads to suppuration of the organ, than the non-puerperal variety. 
Formerly it was believed that pelvic peritonitis produced inflammation 
of the ovaries and tubes ; nowadays, however, the evidence seems to be 
in favor of the exact opposite — namely, that disease of the tubes 
induces inflammation of the ovaries and the neighboring peritoneum. 
Therefore, the statistics of Aran, quoted in our last edition, which 
showed that in the majority of the autopsies of "peri-uterine cellulitis" 
the ovaries had undergone suppurative destruction, were wrong, in so 
far as they seemed to indicate that peritonitis usually produces disease 
and destruction of the ovaries. Undoubtedly, acute inflammation of 
the Fallopian tube was the primary cause of the subsequent disease of 



OOPHORITIS. 653 

the ovary and peritoneum. The late Dr. Matthews Duncan was per- 
haps the most prominent writer to place the relation between the dis- 
ease of the ovaries and pelvic peritoneum in its proper light. He did 
so more or less from a clinical and post-mortem standpoint, since he 
performed no abdominal sections. To Lawson Tait is chiefly due 
the credit for having proved the correctness of Duncan's views on the 
basis of operations performed for the removal of the diseased uterine 
appendages. 

The course of an acute oophoritis is very frequently the following : 
first, acute endometritis ; next, salpingitis ; third, oophoritis ; and 
finally, a local peritonitis. Acute inflammations of all these parts 
gradually subside ; their results remain, and in course of time in place 
of an acute inflammation a so-called chronic inflammatory condition of 
the organs is substituted. This "chronic inflammation" is not really 
an inflammation, but either a congestion, a hyperplasia, or an adhesion 
between the different organs. Relapses of the acute inflammation are 
common, and finally suppuration either of the ovary or tube may occur. 
Usually preceding the actual appearance of acute inflammation a con- 
gestion of the ovary and tube occurs, which may persist for a greater 
or lesser time, and finally subside to a return to perfect health or 
increase to an acute inflammatory state. The division of acute oopho- 
ritis into peritoneal, parenchymatous, and follicular will scarcely hold 
good either from a clinical or histological standpoint, and has therefore 
been abandoned. Theoretically, such a distinction would be exceed- 
ingly convenient. 

Pathology. — The stages of acute puerperal inflammation of the 
ovary may still be described, according to Mme. Boivin, as follows : 
first stage, congestion, with increase of weight and rotundity ; second 
stage, the organ double, triple, or quadruple its normal size, tissue soft 
and infiltrated with yellow and violet-colored serum, with slight effusion 
of blood ; third stage, suppuration, pus infiltrated or collected in spots ; 
fourth stage, gray softening, disorganization, the gland becoming dif- 
fluent. The symptoms and pathological changes of non-puerperal 
oophoritis are much less marked and rapid than those just mentioned, 
suppuration usually being the result of repeated inflammatory exacer- 
bations. 

Causes. — The causes of the disease may thus be enumerated : 

Acute endometritis ; 

Acute salpingitis ; 

Pelvic peritonitis ; 

Gonorrhoea ; 

Disturbance of menstruation. 
Any of the causes which have been spoken of as sufficient to cause 
the first three diseases mentioned may through them produce ovaritis. 
A form of oopohritis called blennorrhagic is admitted by most authors as 
corresponding with blennorrhagic orchitis in the male. That gonor- 
rhoea! inflammations of the tubes may readily cause inflammation of 
the adjacent surface of the ovary and pelvic peritoneum will bo easily 
understood when we consider that a drop of infectious or purulent secre- 
tion from the tube may reach the ovary and peritoneum at any moment. 



654 DISEASES OE THE OVARIES. 

Exposure to cold, chiefly at the approach of or during menstruation. 
especially if a catarrhal inflammation of the endometrium and tube or a 
congestion of the ovary already exists, will, in our opinion, very fre- 
quently produce an acute oophoritis. 

Symptoms. — The symptoms of this affection are so intimately asso- 
ciated with those of peritonitis and cellulitis that it is impossible to 
separate them. There is severe pain in one or other iliac fossa, with 
increase of heat, fever, and perhaps chill. Pressure shows the most 
exquisite sensitiveness, and when the part is examined by conjoined 
manipulation this is excessive. By that means the ovary is felt enlarged 
and generally depressed in the pelvis. The tube is usually associated 
with the ovary in the inflammatory process. These symptoms may 
subside upon the occurrence of resolution in four or five days, or pus 
forming within the gland may be discharged into the cavity of the peri- 
toneum, the rectum, the vagina, or the bladder. 

Differentiation. — This is generally impossible. The association of 
the disease with those which have been mentioned as being at times its 
causes, at others its consequences, is usually too intimate for its distinc- 
tion from them. Should conjoined manipulation discover the ovary 
as a round ball, very sensitive, and unassociated with fixation of the 
uterus, a diagnosis would be admissible. Such uncomplicated cases of 
acute oophoritis are seldom met with, acute salpingitis or peritonitis 
usually existing at the same time, as already stated. Still, we have 
met with a few instances of the kind, the reduction of the ovary to its 
normal size by time and proper treatment confirming the correctness 
of the diagnosis. 

Prognosis. — The prognosis is favorable, though never free from an 
element of doubt. This applies entirely to uncomplicated inflammation 
of the organ, chiefly when it is non-puerperal. So far as danger to 
life is concerned, inflammation of the ovary seldom proves serious, with 
the sole exception of the formation of an abscess. As regards restora- 
tion to a normal condition of the ovary, however, in the cases where 
repeated occurrence of the inflammation has taken place, the prognosis 
is almost invariably bad. An ovary which has undergone several 
repeated attacks of inflammation will probably never be restored by 
any means whatever to its normal histological condition or proper physi- 
ological functions. 

Treatment. — In accordance with the rise of temperature, an ice-bag 
should be placed over the affected part and antipyrine or phenacetin 
given to abate the fever. If the temperature does not reach 102° F. 
( which is perhaps an arbitrary limit), one of the best means to reduce 
the inflammation is to apply a blister of generous dimensions (say 
three by three inches) on the abdomen over the respective ovarian 
regions. Hot poultices should usually folloAv the blister until the 
acute inflammation has subsided. Leeches may be applied in place 
of the blister over the ovarian region or around the anus, but in the 
latter situation they are liable to be followed by more severe bleeding 
than is desirable, hence we seldom employ them. Perfect quiet in bed. 
with morphine sufficient to control pain, light diet, mild laxatives or 
enemata to regulate the bowels, comprise the rest of the treatment. In 



OOPHORITIS. Goo 

fact, these cases should be handled almost identically with acute pelvic 
peritonitis, into which the affection may at any time develop. If the 
occurrence of chills with variable rises of temperature and the presence 
of fluctuation in the inflamed ovary should occasion suspicion of sup- 
puration in that organ, if movable and not attached by adhesions to 
Douglas's pouch, its immediate removal by laparotomy is indicated. 
Should it be adherent to the bottom of Douglas's pouch, aspiration 
2>er vaginam, and subsequently free incision into and drainage of the 
abscess, should be practised. Complete removal, however, by abdom- 
inal section would undoubtedly be the safest and most thorough means 
of cure under such circumstances. 

Chronic Oophoritis. — Chronic inflammation of the ovaries is an 
affection of common occurrence, though very little has been ascertained 
as to the exact frequency of the disease. So great is the sympathy 
existing between the uterus and these organs that uterine disorders 
excite ovarian pain very commonly, and give rise to many symptoms 
which are regarded as characteristic of this disease. Again, it is a 
well-ascertained fact that slight attacks of chronic pelvic peritonitis are 
extremely common, and unfortunately we possess no certain means for 
distinguishing such a disorder in the vicinity of an ovary from chronic 
oophoritis. 

In a certain number of cases of uterine disease the patient will com- 
plain of pain of dull, aching character over one or both ovaries, and 
this will very likely be augmented by menstruation. This pain, which 
may be more or less constant, by no means denotes necessarily an inflam- 
mation of the tubes or ovaries. It usually means nothing more than a 
temporary congestion of the ovaries, brought about partly by the uterine 
disease and partly by incidental circumstances, such as exposure to cold, 
unusual exercise, too frequent coition, constipation, etc. We have fre- 
quently felt the ovaries enlarged, tender, somewhat prolapsed, especially 
the left, w T ith symptoms of dragging, bearing down, and local pain ; 
which symptoms readily yielded to the use of iodine and glycerin to 
the vaginal vault, glycerin tampons, and hot vaginal douches, the 
reduction in size of the organ being easily discernible by bimanual 
palpation. 

As regards this frequently-recurring congestion of the ovaries, as 
denoted by increase of size and tenderness of the organ, we have for 
years been inclined to compare it with the hyperemia and swelling of 
the tonsil which so commonly occur on the slightest provocation in 
persons susceptible to diseases of that organ. As the tonsil becomes 
painful, engorged, swollen, and a source of irritation to its possessor. 
often without any known external cause, so may the ovary make its 
presence felt under similar conditions ; and as repeated congestions of 
the tonsil eventually produce a hyperplasia and noticeable enlargement 
of that organ, so may similar occurrences of ovarian congestion ulti- 
mately result in a hyperplasia of the tissues of the stroma of the ovary. 
Besides, repeated inflammatory attacks of the ovary cause a thickening 
of the columnar epithelium covering the free surface of the organ : the 
Graafian follicles, distended periodically by the efforts of the ova to 
escape, do not rupture, and a cystic development of the follicles will 

42 



656 DISEASES OF THE OVARIES. 

ultimately or eventually take place. Thus a direct result of chronic 
oophoritis is the formation of a cystic ovary, usually of the multiple 
variety. 

As a primary affection which creates secondary uterine disorder and 
results in dysmenorrhea, sterility, and hysteria, it is by no means rare. 
Many cases supposed to be obscure and unmanageable ones of uterine 
disorder, many in which the physician is sorely puzzled in accounting 
for the wonderful disproportion between the existing symptoms and 
the degree of uterine disorder discoverable, are due to this affection. 
Instances will not rarely be met with in which, with slight uterine dis- 
placement and a catarrh of no great moment, a patient will be entirely 
unable to stand or walk, except for very short periods of time, will for 
years prove sterile, and will suffer from agonizing dysmenorrhea from 
this cause. 

The prophecy made in the last edition of this work that " the coming 
decennium will prove that in many cases disease of these most import- 
ant organs in the female economy is the source of many ills now attrib- 
uted to that less important viscus, the uterus," has been abundantly 
verified. The records of ovariotomy, oophorectomy, and removal of 
the diseased tubes during the past ten years sufficiently prove the cor- 
rectness of this statement. 

Symptoms. — The symptoms of chronic oophoritis are numerous and 
often perplexing ; no two cases of the affection presenting the same 
features. In some they are physical entirely, while in others the mind 
and nervous system are decidedly involved. In several cases in our 
experience true epilepsy has existed — whether as a consequence or not 
we cannot say, but certainly as a very suspicious complication. 
The rational signs may be enumerated as — 

Dysmenorrhoea ; 

Fixed pain over one or both ovaries ; 

Tendency to hysteria ; 

Rarely inability to stand or walk ; 

Sometimes pain on sexual intercourse ; 

Pain and exhaustion after defecation ; 

Pain in rectum, hips, and down thighs ; 

Irregular menstruation ; 

Sterility if both ovaries are diseased. 
Dysmenorrhoea often precedes menstruation by several days. At 
other times it occurs just after the cessation of the menstrual discharge, 
while in a few cases it occurs in the interval between the menstrual 
periods. The last constitutes the intermediate dysmenorrhoea of Dr. 
Priestly, and is a most interesting symptom. At times it occurs with 
great regularity. In one case which occurred in our practice it showed 
itself invariably on the ninth day, and in another on the fourteenth. 
Ovarian dysmenorrhoea produces great nervous disturbance, which ren- 
ders the patient peculiarly prone to seek relief in the use of opium. 

We have met with several cases of this disease in which the patients 
have been unable to stand or walk, except for a few minutes. 

If the ovary be prolapsed, sexual intercourse often proves a source 
of pain, but not otherwise. 



OOPHORITIS. 657 

The menstrual discharge is sometimes very irregular, remaining 
absent for months, and then showing itself as an alarming hemor- 
rhage. In many cases it is quite regular both as to time of occurrence 
and amount. 

The general pelvic hyperemia accompanying chronic oophoritis often 
engenders uterine catarrh. 

That in many cases the patients become pregnant cannot be ques- 
tioned, but, as a rule, where both ovaries are diseased sterility exists. 
It is highly probable that the diseased organs produce diseased or 
imperfect ova. 

Physical Signs. — The patient being examined by touch and con- 
joined manipulation, the uterus will probably, in consequence of con- 
traction of the respective ligament or dragging by the enlarged ovary, 
be usually found to deviate from its normal axis, laterally, anteriorly, 
or posteriorly, and from the cervical canal a thick mucous plug will 
often be found to hang. In Douglas's cul-de-sac on one or on each 
side of the uterus a round, soft, tender body, about as large as a wal- 
nut, will be found. This, when caught between the fingers in con- 
joined manipulation, will prove very sensitive to pressure, which will 
often produce nausea and tendency to hysteria ; and even after it has 
been desisted from a dull aching pain w r ill generally remain. The left 
ovary will usually be found more accessible than the right, the left 
pocket of Douglas's pouch being normally the deeper. 

Prognosis. — We know of few curable disorders which we dread so 
much to meet as this. The clay will probably come when our treatment 
for it will be satisfactory and efficient, but it has not yet been so by any 
means. Many cases will entirely baffle treatment, while all will prove 
little amenable to it. That they often in time recover is true, but re- 
coveries have, in our experience, but little connection with treatment. 
Still, incurability of an ovary afflicted with chronic inflammation of its 
stroma by no means implies absolute necessity for its removal nor 
unqualified persistence of ill-health. It is true the ovary can never 
be entirely restored to its normal condition, but it may often remain 
entirely quiescent, and give its owner so little trouble that she is per- 
fectly willing to bear the occasional twinges of pain, and consequent 
temporary confinement to bed, rather than to have the offending organ 
removed. 

Treatment. — We have nothing better to oifer than the following 
course : If the ovaries be found prolapsed, they should be carefully 
sustained by a light elastic ring pessary, and if the displaced uterus 
press upon them, it should be kept in position. Sexual intercourse 
should be limited as far as possible. If scanty menstruation exist as a 
symptom, one or two leeches should be applied every month to the cer- 
vix uteri. Rest should be prescribed during menstrual epochs, when 
the diseased glands are congested and in a state of nervous excitement. 
Severe exercise or fatiguing occupations should be avoided, and all 
influences calculated to depress the vital forces carefully guarded 
against. Counter-irritation by means of small blisters, applied once 
or twice a month over the abdomino-ovarian region, or by tincture o\' 
iodine, should be kept up for months at a time, and once or twice a 



658 DISEASES OE THE VARIES. 

week the cervix uteri and the whole upper part of the vagina should 
be painted over with tincture of iodine. Every night and morning the 
patient should be directed to use copious injections of warm water into 
the vagina in the manner elsewhere explained. For the various ner- 
vous symptoms which accompany the affection the bromide of potas- 
sium in ten- to fifteen-grain doses will be found very beneficial. Utero- 
gestation. which secures the ovaries from monthly congestions for nine 
months, is always much to be desired under these circumstances. 

The local use of galvanism in mild currents not exceeding 20 M. A.. 
one electrode, the positive, being placed in the vagina (metal ball cov- 
ered with wet absorbent cotton), the other on the abdomen over the 
affected side, for fifteen to twenty minutes three or four times a week. 
will often give very great relief in chronic oophoritis, allaying pain 
and to a certain extent reducing congestion and hyperplasia. Too 
much must not. however, be expected from this treatment, the good 
effect of which will usually be felt in half a dozen sittings if at all. 
The current should never be so strong as to give pain or to do more 
than redden the abdominal skin. 

In cases where decided inflammatory enlargement of the ovaries 
exists, and in which the pain renders the patient's life a burden, we are 
justified in considering the advisability of giving her permanent relief. 
even at some risk, by removing the ovaries. If a woman, however, should 
be near the natural change of life, this operation would probably not be 
justifiable, since the menopause would in itself effect a cure of the case. 

Before closing this chapter we would like to say that our views 
regarding the entire curability of this affection have not materially 
changed since the publication of the last edition of this book. We 
regret that treatment in our hands has been far too often ineffectual or 
but temporary in its beneficial results. Still, we wish to modify to a 
certain extent the statement made by us ten years ago. which implied 
that treatment of this disease was usually ineffectual. In cases of not 
too remote origin we have found local counter-irritation, hot douches, a 
sojourn at Kreuznach. Franzensbad. and Schwalbach. productive of 
great benefit, which we attribute especially to the use of the brine and 
moor baths systematically given at those resorts, and also to a change 
of climate and absence from marital relations. Indeed, we have seen 
in several instances pregnancy result after a return from a cure in those 
baths in cases where the inflammation and adhesion of the ovaries had 
led us at first to doubt the possibility of such an occurrence. Hence 
we do not wish to discourage either the practitioner, or through him 
the patient, from employing whatever means science affords us for the 
relief of this disease. Only in the very last emergency would we con- 
sent to a removal of ovaries which are diseased in no other way than as 
the result of chronic inflammation. 



Abscess of the Ovary. 

Definition. — An abscess of the ovary means the substitution of a 
greater or lesser part of the organ by pus in consequence of an acute 
inflammation. 



ABSCESS OF THE OVARY. 



659 



Pathology. — As already stated in the preceding section, suppurative 
destruction of the ovarian tissue takes place much more frequently as 
the result of puerperal inflammation of the organ than in the non-puer- 
peral state. Our subject confines us to the latter condition. Usually, 
acute inflammation of the ovary which is so intense as to terminate in 
suppuration is accompanied by pelvic peritonitis and more or less exu- 
dation in Douglas's pouch. In consequence of this exudation, and the 
ensuing adhesions with interruptions of circulation, the ovary breaks 
down and undergoes suppurative destruction. Often a number of 
attacks of this kind are necessary before the ovarian tissue succumbs 
to suppuration. 

Frequency. — In former times abscess of the ovary of the non-puer- 
peral variety was thought to be exceedingly rare ; but at present, when 

the frequency of abdominal sec- 
Fig. 300. tion enables us to investigate 

many pathological conditions of 
the uterine adnexa which for- 
merly were merely guessed at, 
we have become convinced that 
non-puerperal abscess of the 





Abscess of Both Ovaries, with Pyo-salpinx (Munde). 
The sacs of the abscesses are open, having been torn during their detachment from the adhesions. The 

dilated tubes are above. 



ovary is by no means as rare as was supposed. [While the majority 
of operators report having met with more cases of pyosalpinx or pus- 
tubes than of pyo-oophoron or pus-ovary, I have chanced to see more 
of the latter, having operated on eight cases during the last few years 
in which the tube was only secondarily involved. All of the patients, 
it may be mentioned, recovered. — P. F. M.] 

Diagnosis. — The diagnosis is not easy to make. The presence of a 
pelvic inflammation, and even of encysted fluid in the pelvic cavity, is 
not difficult ; the aspirator inserted per vaginam indeed reveals to us 
that the fluid is pus, but whether it is pus in the ovary or pus in the 



660 OVARIAN TUMORS. 

Fallopian tube is not always easy to say. In the cases where w r e have 
had opportunity to verify the diagnosis by laparotomy we have found 
that an abscess of the ovary had a spherical shape, whereas that of the 
tube was oblong, more like that of a sausage. At times pus is found 
in both tube and ovary, and then a differential diagnosis is absolutely 
impossible. To distinguish betAveen an intra-peritoneal abscess and 
one in the pelvic cellular tissue is usually not so difficult, since the 
intra-peritoneal abscess can generally be moved slightly on bimanual 
examination, whereas the pelvic abscess, being in contact with ,the pel- 
vic wall and outside of the peritoneal cavity, is absolutely immovable. 
Usually the ovarian abscess is surrounded by adhesions following pelvic 
peritonitis, and attached by them to the neighboring surfaces of Doug- 
las's pouch or intestine. In this respect also an ovarian abscess differs 
from a pyo-salpinx, which may be entirely free. The pus of an ova- 
rian abscess may be perfectly sweet and inodorous or quite offensive, 
probably in the latter case due to adhesion of the intestine and trans- 
mission of intestinal gases. 

Treatment. — The diagnosis being made of an abscess of the ovary, 
its removal is at once indicated. There can be no two opinions on this 
subject. Ovarian abscess, it is true, seldom ruptures into the perito- 
neal cavity, simply because the adhesions and the inflammatory thick- 
ening of the pus-sac do not favor rupture. Still, no one can know 
when such an accident might occur, and fatal peritonitis will of course 
be the result. Besides, there is no other cure for the disease than the 
removal of the pus-sac and its contents. To aspirate, open, and drain 
it per vaginam is admissible only when the sac is adherent to Douglas's 
pouch. This might be proper treatment if only one ovary were dis- 
eased ; but if both have become abscesses nothing short of' their abso- 
lute removal by laparotomy is indicated. This question, however, may 
still be said to be somewhat sub judice, since undoubtedly an abscess 
of an ovary which is firmly adherent to the bottom of Douglas's pouch 
can be opened and probably cured by vaginal treatment with much less 
danger than accompanies its removal by abdominal section. The one 
objection to the vaginal puncture is always that the after-treatment may 
be very much prolonged, may eventually fail in effecting a cure, and 
that laparotomy may ultimately be required. No hard and fast rule 
can be laid down for the treatment of these cases, each one of which 
should be judged and treated on its own merits. 



CHAPTER XLII. 

OVARIAN TUMORS. 

To the labors of Rokitansky and Virchow is chiefly due our present 
complete knowledge of those pathological developments called tumors. 
Even since the publication of the last edition of this work advances 
and discoveries have been made which have cleared up certain doubt- 



OVARIAN TUMORS. 



661 



fill points in the histological significance of tumors of the ovary, 
and we are now able to pronounce authoritative judgment on nearly 
all the questions concerning the pathology, cause, and prognosis of 
these growths. As regards their treatment — that is, their cure by 
removal — but little remains to be discovered, since nearly every phase 
and variety of the disease has been explored over and over again by 
numerous operators, who have the " courage of their convictions " based 
on wide experience. 

In order to facilitate the clinical study of ovarian tumors we have 
presented them in the following table under two chief headings — first, 
as to their being solid or containing cystic elements, and, second, as to 
their benignancy or malignancy. We also introduce a table presenting 
other abdominal pelvic cysts resembling ovarian cysts so closely that a 
differentiation is exceedingly difficult. 



Ovarian 
tumors. 



f Solid tumors. \ 

I 



^Cystic tumors. 



Benign tumors. 



Malignant tumors. 



Solid abdominal tumors re- 
sembling ovarian tumors. 



Abdominal and pelvic cysts 
resembling ovarian. 



I 



Carcinoma ; 

Sarcoma ; 

Papilloma ; 

Fibroma. 

Cysto-carcinoma ; 

Gysto-sarcoma ; 

Cysto-fibroma ; 

Cysto-papilloma ; 

Dermoid ; 

Ovarian cysts, monocystic and polycystic 

(myxo-adenoma) ; 
Hydrops folliculorum. 
Papilloma ; 
Fibroma ; 
Cysto-papilloma ; 
Dermoid ; 
Myxo-adenoma ; 
Hydrops folliculorum. 

Carcinoma / Solid ; 

Sarcoma \ Cystic ; 

Pediculatecl fibroids ; 

Solid tumor of spleen ; 

Displaced kidney ; 

Tumors of abdominal wall ; adipose en- 
largement ; 

Cysts of broad ligament : 

Uterine fibro-cysts ; 

Encysted peritoneal dropsy : 

Renal, hepatic, and splenic cysts : 

Parasitic cysts ; 

Hydrosalpinx : 

Cysts of the omentum, mesocolon, and 
pancreas : 

Tubercular peritonitis : 



662 OVARIAN TUMORS. 

Cysts connected with the spinal cord ; 
Ascites ; 
Abdominal and pelvic cysts j Distended bladder ; 

Pregnancy ; 
Pseudo-cysts ; 
^ Fecal tumor (coprostasis). 



resembling ovarian. 



Under the head of solid tumors enchondroma and osteoma have been 
reported, but the authenticity of the few cases noted is very doubtful. 
Under that of cystic tumors has been mentioned hydrops folliculorum, 
which sometimes creates a sac as large as a child's head. 

Carcixoma. — The ovary may be affected by several varieties of can- 
cerous deposit, which are here placed before the reader : 

1. It may be affected by true scirrhous degeneration. This form of 
cancer is less common than others, occurs usually after middle life, and 
may create a tumor of large dimensions. It develops slowly, and 
presents the physical appearance of scirrhous disease in other organs ; 
it may be a primary malignant development, or it may occur in the 
ovary secondarily, its primary development having been previously 
recognized in some other part of the system. 

2. The ovary may be the seat of medullary cancerous deposit, which 
may originate in the vesicles of De Graaf ; in a corpus luteum, as 
Rokitansky once saw it do ; or in the stroma of the organ. Distension 
sometimes causes rupture of the tunica albuginea of the ovary, and 
then exuberant medullary growth develops in contact with the peri- 
toneum and abdominal viscera. 

3. Scirrhous or medullary cancer may alone or united attack the 
wall of a cyst, and develop either as an endogenous or exogenous pro- 
duction. The cancerous matter so completely invades the cyst-walls in 
some cases as to make it appear that cystic degeneration had occurred 
secondarily to its deposit. 

4. From the wall of a cyst, vascular, arborescent villi may project, 

lining the cavitv, and in time filling- and distending it so as to cause 

© t ■ ■ © © 

the rupture of its walls. Then the exuberant cancerous element 
develops in immediate contact with the peritoneum, and produces either 
a dangerous peritonitis or abundant abdominal dropsy. This is the 
malignant form of papilloma, known in the cervix uteri as epithelioma 
or "cauliflower growth." But all papillomatous growths of the ovary 
are not malignant. 

With this form of cancer colloid degeneration is often associated, 
when it constitutes that variety which has been described by Cruveil- 
hier as alveolar cancer. 

The recognition of the fact that the ovarian disease which affects a 
patient partakes of the character of any one of the forms of cancer 
just enumerated must ever be a matter of great moment, for upon it 
must depend not only our prognosis, but in some cases the deter- 
mination to adopt or reject the operation of ovariotomy. Even if the 
case be one of malignant disease, however, operative procedure may 
accomplish good by prolongation of life. 



CARCINOMA. 663 

The symptoms which generally point to the malignant character of 
an ovarian tumor are these : 

1. The rapid development of a solid tumor in an ovary, with — 

2. Marked depreciation of the strength, vital forces, spirits, and 
general condition of the patient. 

3. The occurrence of oedema pedum and spansemia with a small 
tumor, which are consequently dependent upon a general blood-state, 
and not the results of pressure by the tumor. 

4. Lancinating and burning pains through the tumor. 

5. Cachectic appearance. 

6. The occurrence of ascites without evidences of cirrhosis or other 
hepatic disease, organic disease of the kidneys or heart, or chronic peri- 
tonitis. 

Cystic degeneration of the ovary sometimes advances with great 
rapidity, and is accompanied in its course by rapid emaciation, marked 
physical prostration, ascites, and a cachectic appearance. It may be 
asked whether a case thus complicated would not present the very con- 
ditions which have been pointed out as furnishing grounds for the dia- 
gnosis of malignant disease. Unquestionably, it would. Let it be 
remembered that while these symptoms are mentioned as valuable aids 
to diagnosis, we do not pretend to maintain that they will always enable 
the diagnostician to avoid error. Again, in citing ascites with a solid 
tumor as a most important symptom of malignant ovarian disease we 
do not allude to slight or even moderate effusion with a large growth, 
but a markedly disproportionate amount of fluid — a great deal of 
abdominal effusion with a very small tumor. 

Besides the condition just mentioned, there are two others which 
may create difficulty in differentiation from ovarian cancer : one is 
pregnancy in the middle or latter months, complicated by peritoneal 
effusion ; the other a uterine fibroid existing with attendant dropsy. 
The first may generally be known by its characteristic symptoms ; 
while the second, although it might be recognized by the physical and 
rational signs of uterine fibroids, would very likely give considerable 
trouble in diagnosis. 

When difficult and obscure cases present themselves in which a 
positive diagnosis becomes impossible by ordinary means, paracentesis, 
explorative incision, or both, should be resorted to rather than that 
the patient should be deprived of the prospect for cure held out to 
her by ovariotomy. Very often the most doubtful case may be satis- 
factorily settled by evacuating the abdominal effusion, and passing the 
index finger or the hand through a small opening in the peritoneum so 
as to touch the morbid growth. In certain rare cases even this would 
not suffice to remove all doubt. 

By the means mentioned we have succeeded in making a correct 
diagnosis in many cases of true ovarian cancer, but in reiving upon 
them we have several times failed entirely, pronouncing as cancer what 
afterward turned out to be benign growths. Cystic ovarian tumors 
(especially those distinguished by papillomatous excrescences on their 
surfaces) may unquestionably produce excessive ascites and all of the 
other rational sio-us which we have here recorded as evidences of cancer. 



664 



OVARIAN TUMORS. 



Fortunately, we are not called upon now to rely upon these imper- 
fect means. A very valuable addition to our means for diagnosticating 




Papillary Cystoma of the Ovary, with perforating papillomata (Olshausen). 

carcinoma of the ovary has recently been put at our disposal by Drs. 
Foulis of Edinburgh and Thornton of London, each working without 
knowledge of the other's labors. They have found that if the peri- 
toneal fluid which has been in contact with malignant ovarian tumors 
be examined microscopically, it will be very generally found to contain 
germs which will announce the fact and put us on our guard as to the 
nature of the disease. Their statements may be found in the British 
Medical Journal for July and September, 1877, and are well worth 
careful study. 

Sarcoma is another variety of malignant disease affecting the ovary. 
It is less common than carcinoma, and is usually of the spindle-celled 
variety, with more or less admixture of round cells. Sarcoma of the 
ovary may exist alone, or it may invade myxoid cystomata (the ordi- 
nary ovarian polycyst), or carcinomata and fibromata. In this combi- 
nation the tumors may grow enormously large, and the malignant 
degeneration spread to neighboring organs or to distant portions of the 
body by metastasis. Both ovaries are often affected. Progress is less 
rapid than carcinoma, but equally certain. Early removal may, how- 
ever, effect a cure. 

Papilloma. — The hypertrophy of papillae may take place from the 



FIBROMA. 665 

Surface or from the Avail of a glandular cyst, and at an early stage does 
not denote malignancy. It is simply a warty growth, like that disease 
in other parts of the body. The stroma of the ovary may have under- 
gone more or less cystic development, or the ovary may be scarcely 
larger than normal. [I have seen such papillomatous excrescences on 
the outside and inside of large cysts, their size being often as large as 
a fist ; and in one the ovary, of normal size, was studded with small 
warts. These papillomata may spread to the neighboring organs, and 
in one case, masked by ascites, in which I made an exploratory incision I 
found ovaries, uterus, bladder, and rectum all inextricably involved in 
one mass of papillomatous growths, which also spread to the pelvic wall. 
An attempt to detach and isolate the different parts of the mass resulted 
in profuse hemorrhage, and was abandoned. The abdominal cavity was 
flushed with warm water, a drainage-tube inserted, and the wound 
closed. The tube remained in place two weeks, and, there being then 
no more secretion, was removed. The patient made a good recovery, 
and when seen a year later was free from ascites, although the tumor 
was apparently unchanged. Her physician reports to me, four years 
after the operation, that she is apparently perfectly well, and that the 
tumor has become hard. — P. F. M.] 

Although these papillomata are not malignant at the outset, there is 
no certainty that they may not at any time become so. 

Fibroma. — This form of tumor is rarely met with in the ovary, and 
never attains a very great size. Nearly all the cases of fibrous tumor 
of the ovary reported in former times were errors of diagnosis, usually 
being merely uncommonly solid multilocular cysts of that organ, which 
to the touch felt like solid tumors. Thus, Peaslee in his classical work 
on Ovarian Tumors (p. 26) reported one removed by Thomas, who, 
however, in the last edition of this work disagrees with Peaslee's dia- 
gnosis, on the ground that the tumor " consisted of loose fibrous ele- 
ments, forming numerous loculi, about the size of a hickory-nut, which 
were filled with honey -like material." It was evidently a myxo-ade- 
noma, composed of innumerable small cysts, which we all see very fre- 
quently, and the nature of which is well known to us at the present 
clay. The custom of calling these multilocular cysts with considerable 
solid tissue " cysto-fibroma " and " cysto-sarcoma," which obtained in 
those days, added to this confusion. True fibroma of the ovary occur 
in a limited number of cases, every operator of prominence having 
probably seen one or two. Their size usually does not exceed that of 
a child's head, but Foerster, Van Buren, Thomas, Spencer Wells, and 
others have each removed one larger than an adult head. [I showed one 
weighing 773 grams, or about \\ pounds, to the N. Y. Obstet. Society two 
years ago, removed by me from a single lady twenty-six years of age. 
and in the discussion Dr. Coe stated that there were only thirty or forty 
on record, he having, as pathologist to the New York Woman's Hos- 
pital, seen about half a dozen. 

Fibro-cysts — and mine was just beginning to undergo that degene- 
ration — of the ovary, according to Dr. Coe, are even more rare than 
fibroids, the only one he had seen being one removed by Dr. Thomas, 
containing a quart of fluid. At this meeting mention was made of a 



666 



OVARIAN TUMORS. 



fibroid of the ovary removed by Dr. H. M. Sims, and of a fibro-cyst 
of the ovary removed by Dr. Wylie. — P. F. M.] 

Fibroids of the ovary were met with twice in 500 ovariotomies by 
Spencer Wells. Either the whole ovary may have undergone the 
fibrous degeneration, or [as in my case and one reported by Olshausen 




-^ 



Fibroma of Ovary just beginning to undergo cystic degeneration (Munde). 
P, pedicle; OA, adhesion. 

— P. F. M.] the fibroma sprang from a comparatively small point on 
the surface of the ovary, possibly having developed from a corpus 
luteum, as is suggested by Klob, Klebs, and Rokitansky. Ovarian 
fibroids usually grow slowly, but cause more pain and excite ascites 
more early than ovarian cysts of corresponding size. Their pedicles 
may be twisted and alarming symptoms arise, to be referred to later on, 
when torsion of the pedicle of the ovarian cysts will be considered. 

The diagnosis is difficult, a pediculated myo-fibroma of the uterus 
being the one thing for which the ovarian fibroid is most easily mis- 
taken. The greater amount of pain and the failure to find the ovary 
on that side may aid in the diagnosis. Bilateral fibromas of the ovary 
are reported by Spengler and Winckel. 

Early removal by laparotomy is the only treatment indicated. 

If in one of the solid tumors just mentioned cysts develop themselves 
as essential parts of the growths, we give them the names of cysto- 
fibroma, cysto-sarcoma, or cysto-carcinoma. 

Cysto-Carcinoma. — The formation of fluid collections may occur 
with cancer of the ovary in three Avays : 1st, cysts may develop in the 
structure of scirrhous and medullary cancers, as they do in that of sar- 
comata ; 2d, a fluid or cystic tumor, primitively benign, may develop 
malignant material in its cyst-wall ; 3d, a large medullary cancer may, 
by cell-infiltration and disintegration at its centre, form within itself a 
mass of fluid. The condition may consist then in cancer complicating 
cystic degeneration or in cystic degeneration complicating cancer. 



DERMOID CYSTS. 667 

According to Scanzoni, the cancerous mass may develop in the tissue 
of the cyst-walls and project either internally or externally, or it may 
grow from the walls by pediculated or sessile tumors filled with medul- 
lary material, which are soft, tumefied, and very vascular. In the same 
tumor both colloid degeneration and medullary cancer may be met 
with. 

The ovarian limits do not always confine these fatal growths. At 
times they pass them and affect the peritoneum or other neighboring 
parts. This tendency to eccentric development accounts for the pro- 
tuberances, the size of the fist, so often serving as a means of diagnosis 
of ovarian cancer. The distinguishing characteristic of cystic cancer 
is its rapidity of development. In a few months it often reaches a size 
which sarcoma or even cystic degeneration would not attain for several 
years. 

Surgical treatment holds out little hope in these cases. According to 
our experience, ovariotomy performed upon patients thus affected almost 
invariably results fatally. Nevertheless, even as a forlorn hope its 
propriety should be considered. 

The prognosis in this disease is graver and the limit of life shorter 
than in any other affection of the ovaries. 

Cysto-Sarcoma of the ovary means nothing more than the associa- 
tion of a sarcomatous degeneration of the organ with cystic formation, 
either the sarcoma or the cyst being the first to develop. Much con- 
fusion formerly existed in these nomenclatures, the word "sarcoma" 
(from oap$ , flesh) being used to indicate the presence of more or less 
solid elements in the polycystic tumor. At one time, indeed, these 
tumors were considered to be malignant or bordering on malignancy. 
Now, however, we know that these growths are composed of glandular 
and papillary tissue, with epithelial and connective tissue and vessels, 
and contain numerous large and small cavities filled with thick and 
thin, clear and opaque, fluid and colloid matter. But they are not 
malignant, and, to avoid the old confusion, are no longer called " cysto- 
sarcoma," but u myxo-adenoma," or glandular growths filled with 
mucus-like secretion. 

True cysto-sarcomata may, like all malignant growths, rapidly assume 
a very large size. But the cases reported in the older books by this 
name as instances of enormous growth were undoubtedly common non- 
malignant ovarian polycysts. 

Cysto-sarcoma of the ovary is, we believe, by no means as common as 
cysto-carcinoma. The same rule applies to this variety as to all ovarian 
tumors — viz. the earlier removal by abdominal section, the better the 
chances of the patient for recovery. If the sarcomatous degeneration 
has already spread to neighboring organs, of course permanent recovery 
is out of the question. 

Cysto-Papilloma and Cysto-Fibroma have already been briefly 
referred to under Papilloma and Fibroma, and need not be further dis- 
cussed here. The development of papillomata on the interior of ovarian 
cysts will be again mentioned later on. 

Dermoid Cysts. — In various parts of the body, the orbit, the floor 
of the mouth, the brain, the eve, the anterior mediastinum, the lungs, 



668 



OVARIAN TUMORS. 



the mesentery, the testicles, and the ovaries, a peculiar cyst containing 
fat, teeth, hair, cholesterin, cartilage, and bone is sometimes found. Its 
wall gives evidences of the existence of sweat-glands, sebaceous follicles, 
papillae, and an investing epithelium, so that the microscopic appearances 
of the wall resemble closely those of the skin. Many fanciful theories have 
been indulged in as to the origin of these peculiar growths. It is now 
generally believed that they are the result of an irregular and eccentric 

Fig. 303. 




Portion of the Wall of an Ovarian Dermoid Cyst : a, wall ; b, elevations composed of 
fatty and cutaneous tissues; c, hairs ; d, teeth (Ziegler). 

development of the tissues of the foetus during intra-uterine life. It 
was Lebert who advanced the theory that from the elements present 
spontaneous generation of a portion of skin occurs, and this being given, 
we have, as Dr. Farre expresses it, " the basis out of which many of 
those products spring." 

M. Pigne has analyzed 18 cases with reference to the period of life 
at which they were found, with the following results : 

5 existed in virgins under twelve years ; 

6 children from six months to two years ; 
4 " the female foetus at term ; 

3 " foetuses cast off at eighth month. 

Dermoid tumors vary in size from that of a hen's egg to that of the 
adult head, but very rarely grow larger. They are hard and generally 



DERMOID CYSTS. 



669 



<rlobular. One ovary is usually affected, and by only one tumor, but 
instances are on record where a single ovary contained a large number. 
They usually consist of fat, long hairs, teeth, skin, and traces of bone 
intermixed. The teeth are usually imbedded in the cyst-wall or attached 
to pieces of bone, and are sometimes very numerous. Schnabel 1 records 

a case in which they exceeded 
one hundred in number, and 
Ploucquet 2 one in which they 
amounted to three hundred. 
[Out of 15 cases of dermoid 
cysts operated on by me, in 3 
both ovaries were affected in 

Fig. 305. 



Fig. 


304. 






^^pgffrt 










m W$M 






W WMM-m 






m ^^mm 


Jr* §SJ£ff 


SI 


arl'i*® '^ 


PI 

fPwJB 

1mm 


H 


w ' *' 4 


||||Jiiln. {§111 




v..: ' : 


!'• "1 


HMh 


Cj jl 


& ' 1 


*? 


* . 


'"/ ^ 1 


■ ; ••• 










Switch of Hair, five and a half feet long, from 
Dermoid Cyst (Munde). 



Balls of Fat from Dermoid Cyst 
(Munde). 



this manner. One of these three women was pregnant five months : 
from another, a single woman, thirty-nine years of age, I removed the 
switch of hair shown in the adjoining diagram. When removed it was 
two and a half feet long, but after dissolution of the fit contained in 
it by immersion in ether, it lengthened to five and a half feet, being 
nearly as thick as the arm at the wrist in its entire length. From 
another came the peculiar bullets of fat shown in Fig. 305, each ball 
containing a single hair — P. F. M.] 

Although in themselves innocuous, and not likely to increase 
rapidly or to attain any great development, they sometimes sot 
up very serious and even fatal disturbance by one o\' three methods: 

1 Kiwisch, op. tit. - Becquerel, op. tit. 



670 



OVARIAN TUMORS. 



by creating suppuration and abscess on account of the irritation kept 
up by a foreign mass ; by perforation and discharge into the peritoneum ; 
or by the cyst which contains the dermoid elements secreting fluid and 
changing its character to that of a fluid tumor. [Out of 150 ovarian 

Fig. 306. 




Double Dermoid Cysts, removed during pregnancy : recovery (Munde). 



tumors removed by me, 4 were large cysts having as bases dermoid 
tumors containing fat and hair, and in 1 case a small fragment of bone. 
In these cases the cysts containing the dermoid elements were not in 
communication with the large cysts filled with fluid colloid which 
constituted the mass of the tumor. In 2 cases the tumor was nearly 
removed when a cyst filled with fluid, fat, etc. was opened into. The 
large cysts appeared exactly like ordinary multilocular cystoma. — 

t. a. t.] 

Very often they are discovered by accident only. Physical explo- 
ration reveals a hard, round mass, often painful upon touch, and, unless 
the size prevent it, perfectly movable. But more frequently their 
tendency to inflame spontaneously produces pain and even an elevation 
of temperature, which leads to their discovery, or their pedicle becomes 
twisted, or they are bruised accidentally, and then detected by exami- 
nation. In one case, reported by Dr. Janvrin to the New York 
Obstetrical Society (see Am. Journ. Obst., vol. xix., 1886), the 
patient's attention was first attracted by a bunch of hair protruding 
from the rectum. This, after repeated efforts, she pulled away. Some 
years later her abdomen began to enlarge, two ovarian tumors were 
diagnosed, and on removal found to be both dermoid, one of which had 
perforated into the rectum. Pelvic abscesses have been frequently 
witnessed (several times by P. F. M.), the intra-peritoneal and der- 
moid character of which was proved by the removal of hair through 
the sinus of the supposed abscess in the posterior vaginal vault. 

Dermoid cysts of the ovary should be removed by laparotomy as 



DERMOID CYSTS. 671 

soon as discovered, although it is true that the diagnosis can usually 
not be made until after their removal. If we were to find a small tumor, 
of the size of a duck's egg to a cocoanut, in the pelvic or lower abdom- 
inal cavity, which was more or less tender on pressure, and had a tense, 
almost solid feel, we should feel inclined to hazard the guess that it 
might be a dermoid, and advise early removal, for fear of torsion of 
the pedicle or inflammatory adhesions. 

In our experience there are three chief periods in female life which 
seem to excite the dormant growth of dermoid tumors of the ovary : 
1, puberty ; 2, marital relations ; and 3, pregnancy and parturition. 

Laparotomy for dermoid cysts is relatively as successful as for ordi- 
nary ovarian cysts. The contents of dermoid cysts, unless suppuration 
has occurred, are no more irritating or infectious to the peritoneum or 
womb than the fluid of ordinary ovarian cysts. 

We have now reached the proper point for the consideration of the 
subject of ovarian cysts and cystomata which calls, on account of its 
paramount importance, for the closest investigation on the part of the 
gynecologist. That it may receive this we leave f its study for a separate 
chapter. 

Before proceeding, we wish to clear up any possible doubts which 
may still exist, not only as to the exact pathological status of cysto- 
sarcoma of the ovary, which we have distinctly pronounced malig- 
nant, but merely on account of the malignancy of its sarcomatous 
elements, not because tumors composed of both solid and fluid con- 
stituents need necessarily be malignant; but we also wish to disabuse 
the reader of any possible misconception he may have as to another 
old term — viz. "colloid." This word is derived from xoXla, "glue," 
and etdoz, "like," and that is all it really means. Multilocular ova- 
rian cysts containing this colloid or glue-like matter were formerly 
thought to be, if not actually malignant, at least on the verge, and 
the "colloid" character was supposed to be the proof. Even in the 
last edition this peculiar matter — due, it is believed, to the breaking 
down of the stroma of the organ into alveoli — was pronounced " not 
in itself a malignant affection, but one which seems to contribute a 
connecting link between cancer and the benign degenerations." At 
present, however, we are entirely assured that this colloid matter, whilst 
it may occur with cancer, is in no way associated with malignancy, but 
practically important only in that it is more difficult to evacuate, and 
may necessitate a longer incision to enable the only partly emptied 
tumor to be delivered. 

In conclusion we will quote the words of Virchow l on this point : 
' You may say colloid cancer, colloid sarcoma, colloid fibroma. Here 
' colloid ' means nothing more than jelly-like." 

1 Cellular Pathol, p. 512. 



43 



672 OVARIAN CYSTS. 



CHAPTER XLIII. 

OVABIAU CYSTS. 

This disease consists in the development of cysts within the ovary 
■without coincident growth of solid elements, such as fibroma or 
carcinoma. Of all the varieties of ovarian tumor, it is the most 
commonly met with, and hence for the practitioner it is the most 
important. It is. fortunately, too. that which above all others is most 
susceptible of relief by surgery. 

Pathologists are still at variance with reference to the origin of 
ovarian cysts. While some with Wilson Fox l agree that " all the 
forms of cysts met with in the ovary originated from the Graafian 
follicles, and that the multilocular forms are not the results of any 
special degeneration of the stroma." others, like Wedl, doubt their 
follicular origin entirely, and others still, with Rindfleisch. admit two 
different sources of cystic formation — one the follicles, the other the 
interstices, of the stroma. 

" In many cases." says Rokitansky. 2 " they are undoubtedly formed 
from the Graafian follicles, and it appears that an inflammatory pro- 
cess is particularly liable to give the first impulse to this metamor- 
phosis. They are probably, however, as often new formations from 
the beginning." 

" It was formerly very generally supposed." says Wedl. 3 ; * that the 
cysts in the parenchyma of the ovary originated in the Graafian 
follicles, but no direct proof of this was ever given." 

Lucke, 4 one of the latest and most reliable authorities, takes even 
stronger ground against it than Wedl did. After quoting Rokitansky's 
views, he goes on to say : ; * But we have already stated that cysts can 
only form in the connective tissue and only after a long-continued 
irritation, and that it does not look at all probable that such cysts 
should form by spontaneous exudation. As far as the cystoids of the 
ovary are concerned, theory certainly is not admissible. These tumors 
are essentially cysts from broken-down tissue." 

While experimental pathologists are testing this question we may 
for the time assume that there are two entirely different pathological 
processes by which true ovarian cysts are generated : 

1st. The follicles of De Graaf become filled with a colloid material. 
due to abnormal secretion from their walls, and. according to Rokitan- 
sky and Rindfleisch. 5 probably the result of inflammatory disease of 
the wall of the follicle. This is not the insignificant hydrops follicu- 

1 Med.-Chirarg. Trans., 1864. * Op. cit.. p. 249. 

3 WedTs Path. HistoL, p. 402. 

4 Chapter on Tumors in Billroth and Pitha's Manual of General and Special 
Surgery. 

5 Op. eiLj p. 515. 



OVARIAN CYSTS. 673 

lorum which creates small cysts, but a true colloid degeneration of the 
follicle of much more serious import. 

2d. A development of cysts may occur in the stroma of the ovary 
without connection with the follicles. In this case, according to Wedl, 
"the cyst consists in an excessive augmentation of volume of the 
areolae of the areolar tissue and of the papillary new formations com- 
posed of connective tissue." In this view Waldeyer coincides in his 
excellent treatise on the ovary. 1 

Lucke makes Rokitansky's view as to the mode of formation of 
these cysts in the stroma so clear that we use his words instead of quot- 
ing the original : " Cysts may also be generated by exudation into new- 
formed connective tissue — the fluid distending the different bundles, 
and as they intersect in all directions, the globular form is the result ; 
thus numerous small spaces communicate with each other, from their 
walls new cysts start, and thus very complex tumors can be formed." 
Rindfleisch 2 accepts both of these sources of ovarian cystoma in the 
following words : " An exact investigation also proves that at least 
the majority of all ovarian cysts proceed from Graafian follicles; 
while, on the other hand, until further information, a different mode 
of origin must be accepted for a group of cysts, although not so large, 
yet at the least just as important." 

The development of a substance resembling the glandular element 
of the ovaries, and constituting the nidus of cysts, has recently 
attracted considerable attention. In 1862, Sir Spencer Wells pro- 
posed for this the name of "adenoma" or "adenoid tumor." Further 
investigations appear to have satisfied pathologists that a degree of 
adenoid development occurs in every true ovarian cystoma. Wells 
himself, in his work on Diseases of the Ovaries, considers under the 
head of adenoid tumors all simple, multiple, and proliferous cysts ; and 
Delafield 3 declares that "in the ovaries most of the compound cysts are 
adenomata, with dilatation of the follicles." Klebs strongly advocates 
this view. As adenoma is, then, a frequent element of ovarian cysto- 
mata, it requires no separate and special consideration. 

Until a recent period considerable attention has been paid to the 
character of ovarian cysts, based upon the existence of a few and of 
many cysts. Pathologists are beginning to lay less stress upon this 
feature than they formerly did. Rindfleisch declares that all are 
multilocular in the beginning, and that they become paucilocular, and 
even, in rare cases, unilocular, by fusion of adjacent cysts by breaking 
down of dividing septa. It must be admitted, however, that there is 
one class of tumors the distinguishing characteristic of which is the 
existence of a few cysts only, one or two of which are usually very 
large, and another which is specially marked by numerous small cysts. 
The first constitutes the oligocystic tumor of Peaslee ; the latter the 
polycystic tumor; or, as they are likewise styled, paucilocular and 
multilocular. 

Each class has usually certain well-marked features, the recognition 
of which is of value in a practical point of view. The first is thus 

1 Waldeyer, Eierstock und Ei, Leipzig, 1870. - Op. ciL, p. 515, 

8 Post-mortem Examinations and Morbid Anatomy. 



674 



OVARIAN CYSTS. 



described by Rindfleisch : " Multilocular tumors up to the size of a man's 
head, or unilocular cysts up to two feet in diameter, with smooth but 
little adhering surface, and comparatively thick, fibrinous walls, which 
are very commonly covered at their inner side with cauliflower-like or 
more tuberous papillary excrescences." This is the form of tumor 
which he regards as due to colloid degeneration of the Graafian follicles. 

The second variety he describes in these words : "At the place of 
one ovary (the other, as a rule, is healthy, while in the first form the 
disease is often of both sides) there lies a tumor not infrequently far 
above the size of a man's head, which is composed of several large and 
very many smaller, and even the smallest, cysts. The larger cysts are 
often constricted, and exhibit at these places the remains of former 
partition-walls in the form of fenestrated membranes or ramified vascu- 
lar strands, which evidently succumb to a gradual maceration. The 
surface of the tumor is probably always connected with the peritoneum 
by a large number of inflammatory adhesions, upon w T hich larger venous 
vessels run to and fro. The w^alls of the cysts are comparatively thin 
and easily torn." These tumors he regards as due to colloid degenera- 
tion of the stroma. 

While the statement of Rindfleisch, that no "fundamental signif- 
icance " can be attributed to the unilocular or multilocular character of 
these tumors, is correct from an anatomical point of view, it is not the 
less so that the practitioner is greatly aided in prognosis and treatment 
by a recognition of the difference between the two forms of tumors just 

♦ Fig. 307. 




Monocyst of Left Ovary : glandular degeneration of cervical mucosa. 

LT, left tube ; RT, right tube ; V, large uterine glandular polypus ; LR, left round ligament; RO. right 

ovary; SS, small cyst in right ovary; H, small cyst of broad ligament (natural size; Beigel). 

described, and also that which exists between them and another, which, 
being composed of both cystic and solid elements, receives the name of 
compound. We therefore proceed to consider the varieties of these 
growths in reference to the points mentioned, and to recapitulate suc- 
cinctly what has been already said. 



OVARIAN CYSTS. 



675 



Our idea of the true character of the majority of ovarian cysts is, 
that they represent a more or less uniform enlargement of every por- 
tion of the affected ovary, one element often predominating over 
another, but all being to some extent involved. Thus, in one case the 
Graafian follicles naturally present in a normal ovary become dis- 
tended, some more, some less, and the tumor then consists of thousands 
of cysts of greater or lesser size ; at the same time the walls of these 
cysts may remain thin or may develop in thickness proportionate to the 
dimensions of the cyst. Vessels, lymphatics, nerves, epithelial lining, 
and papillary protuberances keep pace with the development of the 
rest of the organ, and, as there is no apparent limit to that develop- 
ment, we find ovarian tumors containing all the component parts of 
the parent organ developed to their utmost capacity. But this is not 

Fig. 308. 




Cystic or Vesicular Degeneration of the Ovary: Hydrops Folliculorum (Beigel). 



always the case, since one element often predominates over the other 
in the process of morbid development, and one ovarian tumor consists 
almost entirely of one sac or a combination of cysts, with but very little 
solid material; whereas another presents more solid than fluid constitu- 
ents ; and a third, again, is composed entirely of the solid elements of 
the ovarian stroma. The proper name, then, for these different forms of 
ovarian tumors is adenoma, meaning more or less uniform development 
of the ovarian glands. According as the contents of the cysts are fluid, 
which is usually the case in oligocystic tumors, they are called cvsto- 
adenoma ; or, if the contents are thick, as in multilocular tumors, myxo- 
adenoma. The latter we would consider the generic term for ovarian 
cysts. 

Ovarian cysts are characterized by three marked features : first. 
C} r sts with one or very few large compartments: second, cysts with a 
great many small compartments divided by thin cyst-walls or thick 
trabecule ; and third, cysts which are composed of solid and fluid ele- 
ments in varying proportions. The first constitute the class styled the 
monocystic, unilocular, paucilocular, or oligocystic tumor ; the second. 



676 



OVARIAN CYSTS. 



that known as the multilocular or polycystic tumor ; and the third, that 
which is commonly styled the compound ovarian tumor. " All cystoids 

are multilocular at the com- 
mencement," says Rind- 
fleisch, but uniloculariza- 
tion, he declares, is espe- 
cially frequent in those 
tumors arising from colloid 
degeneration of the Graafian 
vesicles. A true monocyst 




is rare, 



though it 



may grow 



to the size of the uterus in 

vjB\lrJr V * ■ ^rS^nSsF^^^ r ^ e nmt ^ montn of P r eg- 

\3t4MMwW ^f \if--Jlli^Mii nancy. Monocysts will 

usually spring from one 
Graafian follicle, or possibly 
from several which have be- 
come united during their 
development. The fluid is 
always limpid, and very 
much resembles that of cysts 
of the broad ligament. We 
have seen several which at- 
tained the size of an adult 
head. 

The walls of ovarian cysts 
consist of a covering of co- 
lumnar epithelium, the 
proper tunic (tunica albu- 
ginea) of the ovary, and an 
epithelial layer. These walls 
sometimes undergo great hy- 
pertrophy, in rare cases be- 
ing half an inch thick. 

The size to which ovarian 
cysts will grow is truly won- 
derful. It has been already 
stated that unilocular or 
monocystic tumors are rarely 
seen of very great size, but 
instances are on record of multilocular tumors containing over one hun- 
dred pounds of fluid. Goodell removed one weighing 112 pounds, with 
recovery, and Dr. L. A. Rodenstein reported one to the New York Ob- 
stetrical Society in 1878 (see American Journal of Obstetrics, 1879, p. 
303) in which the weight of the tumor removed after death — a previous 
operation having been refused — was 146 pounds. Tumors of this size 
have since been reported by several other operators, and nowadays the 
mere size of an ovarian tumor, while it may attract attention, does not 
necessarily increase the danger of the operation nor lessen the chances 
of recovery. 



Multiple Ovarian Cystoma (Rokitansky). 



CONTENTS OF OVARIAN CYSTS. (HI 

One or both of the ovaries may be affected. 

Old statistics would seem to prove that the right ovary is more fre- 
quently affected than the left ; but, while we have, to our knowledge, 
no modern figures to contradict these statements, our own experience 
leads us to doubt whether there is any difference, more than a merely 
accidental one, between the two ovaries. If anything, we should 
expect the left ovary, which is acknowledged to be more frequently 
inflamed than the right, to be therefore more likely to undergo cystic 
degeneration. [As a slight proof that there is very little difference 
between this disease of either ovary, I will mention that of 68 opera- 
tions by me for plain ovarian tumors, I found 27 to be of the left, 28 
of the right ovary, and 13 of both ovaries together. — P. F. M.] 

Contents of Ovarian Cysts. — This subject has been exhaustively 
investigated by Scherer and Eichwald. 1 By the latter it has been so 
minutely dealt with that little is left to be desired as to the chemistry 
of such fluids. 

These contents vary very much, between a clear, albuminous, serous 
fluid and a thick, gelatinous material which will flow through no canula 
and has to be manually removed. The specific gravity may be as low 
as 1007, though usually it is 1018 or 1020. The most important chem- 
ical constituent is an albuminate termed colloid, which is usually more 
dense in polycystic than oligocystic tumors, and denser in small oligo- 
cysts than in the same after having assumed a large size. Tapping 
appears to increase the density of this fluid in oligocysts. 

According to Eichwald, two chemical transformations go on in the 
fluids of cysts simultaneously. Colloid material changes into muco- 
peptone, while the albuminates transuding from the blood are converted 
into albumino-peptone. A species of digestion of the raw material goes 
on under the heat of the body, as Rindfleisch expresses it, and conse- 
quently the larger and older the tumor the more fluid are the contents 
likely to be. Eichwald found these fluids chemically to consist of the 
following elements : 

Of the mucous order : 

Substance of colloid particles ; 

Mucin ; 

Colloid substance ; 

Muco-peptone. 
Of the albuminous order : 

Albumin (and fibrin) ; 

Paralbumin ; 

Metalbumin ; 

Albumino-peptone (and fibro- peptone). 
As an example of the quantitative analysis the following from one 
of Eichwald's oases will serve. 1000 parts contained — 

Water 931.96 

Organic substances 59.77 

Debris 8.27 

1000.00 

1 Wurzhurgev medmnische Zeitschrift, lSt>4. 



678 OVARIAN CYSTS. 

The debris (8.27) contained— 

Salts soluble in water 7.53 

Potas. sulph 0.08 

" chlor 0.59 

Soda? nat 6.29 

" phosph 0.16 

" carb 0.38 

Loss 0.03 

Salts insoluble in water 0.74 

8.27 

Test for Paralbumin. — Leave the fluid at rest in a cool place, filter 
or decant, and thus separate sediment from supernatant fluid. Pass a 
stream of carbonic acid gas through this fluid, and instantly a precipi- 
tate of fine flocculi of paralbumin will occur. 

Test for Metalbumin. — Digest another part of this fluid with abso- 
lute alcohol for three days. Filter off the precipitate and heat with 
distilled water. Filter again, and metalbumin may be precipitated by 
sulphate of magnesia. Paralbumin is precipitated from this fluid by a 
few drops of dilute acetic acid and redissolved by an excess. 

To the naked eye the fluids of ovarian cysts present various appear- 
ances, as they are tinged with blood or pus from hemorrhage or sup- 
puration of the cyst-walls. The varieties generally met with are the 
following : a light-colored fluid like barley-water ; a light-brown fluid 
like infusion of linseed ; a dark red, bloody-looking fluid ; a greenish- 
yellow, semi-solid gelatin ; a purulent fluid of very offensive character, 
closely resembling pea-soup in appearance ; very rarely an intensely 
black fluid ; and in dermoid cysts a grumous, gruel-like mass resem- 
bling pea-soup, which at times is thick like putty or yellow lard. 

Does a true ovarian cyst large enough to call for surgical inter- 
ference — that is to say, larger than the size of a child's head, to which 
hydrops folliculorum sometimes attains — ever contain fluid free from 
albumin ? This is evidently a question of a great deal of importance. 
Wells 1 and Barnes make three groups of ovarian fluid, the first of 
which they declare are devoid of fat and albumin. " Heat and nitric 
acid," says the former, "will neither coagulate nor precipitate them." 
Peaslee 2 expresses himself in these words: " The fluid of an ovarian 
cystoma will probably always be found to contain albumin if it be 
limpid enough to flow through the fine tube of the exploring trocar." 
We can safely say that we have never met with a true ovarian fluid 
which did not contain albumin. 

The solid elements of the fluid of ovarian cysts consist of the results 
of hemorrhage and desquamation and fatty degeneration of epithelial 
structures. In them are found cholesterin, fat-globules, blood-corpus- 
cles, and pigment-cells. 

Microscopical Ajopearance of Ovarian Fluids. — The thinner, serous 
fluids present in comparison with those of colloid character few cellular 
elements. In the latter, under a power of from 300 to 550, Eichwald 3 
found such an amount of morphological elements that the fluid had to 
be diluted with water before it could be examined. He then found 

1 Dis. of Ovaries, Am. ed., p. 92. 2 Op. ciL, p. 116. 3 Op- cit. 



CONTENTS OF OVARIAN CYSTS. 



679 



fatty elements of various size; round cells, some serrated; large, col- 
loid cells ; round cells similar to the pyoid bodies of Lebert or the exu- 
dative corpuscles of Henle ; globular aggregations varying in size ; 
scales of horny epithelium ; crystals of cholesterin ; dark-brown pig- 
ment, etc. 

" On placing a drop of the fluid removed from an ovarian cyst under 
the microscope," says Drysdale, 1 " we usually find a number of granular 
cells, E, some free granular matter, C, and small oil-globules, B ; and 
frequently, in addition to these, epithelial cells of various forms, A, and 

Fro. 310 



4B <§V^& ^ 









Microscopic Appearance of Ovarian Fluid (Drysdale). 

crystals of cholesterin, D. These, together with blood- corpuscles, F, 
the inflammatory globules of Gluge, I, the pus-cells, G H, and disinte- 
grated blood and other cells, may all be sometimes seen floating in either 
a clear or a turbid fluid." 

For the microscopist and pathologist all these are of interest. For 
the ovariotomisc this is the chief point of importance : Is there any 
characteristic pathognomonic cell or element upon the presence of which 
a positive diagnosis of ovarian cyst may be based ? When this question 
can be unreservedly answered in the affirmative, a great advance will 
have been made in this important matter. Spiegelberg, in an interest- 
ing lecture on the diagnosis of ovarian tumors, enumerates cylindrical 
epithelium, colloid cells, cholesterin, etc., and appears to rely upon the 
character of cells furnished by the part from which the material was 
secreted rather than upon any particular cell. 

1 Op. cit. 



680 OVARIAN CYSTS. 

Long ago Nunn pointed out the existence of the ''gorged granule," 
though not as a diagnostic point, and Paget, Bennett, Gluge, and others 
speak of the "granular corpuscle," the "compound granular cell," and 
the "inflammation-globules." In an essay already referred to Dr. T. 
M. Drysdale of Philadelphia has recently described a cell which he 
calls "the ovarian granular cell," which, Avhen found in pelvic tumors, 
he regards as pathognomonic of ovarian disease, and as such he looks 
upon its diagnostic value as very great. 

The cell of Drysdale is represented in Fig. 310, under E. It is a 
granular cell, generally round, sometimes slightly oval, very delicate, 
transparent, and contains a number of fine granules, but no nucleus. 
The granules have a clear, well-defined outline. These cells may differ 
in size, but the structure is always the same. The size usually met 
with is that of a pus-cell. The addition of acetic acid causes the gran- 
ules to become more distinct. When ether is added, the granules 
become nearly transparent, but the appearance of the cell is not 
changed. The cells with which this peculiar corpuscle may be con- 
founded are the pus-cell, lymph-corpuscle, white blood-cell, and other 
cells which resemble them. The appearance of the ovarian corpuscle 
is to the experienced eye a sufficient means of distinction, without the 
addition of acetic acid recommended by its discoverer. Drysdale does 
not assert that the discovery of this cell is original with him, since 
Lionel Beale l gave practically the same description of a cell peculiar to 
ovarian fluid, but failed to give the tests by which to distinguish it from 
other granular cells. 

Although we were formerly sceptical as to the exact validity of this 
cell of Drysdale as an absolutely conclusive evidence of an ovarian cyst, 
we are now disposed to look upon the matter in the following light : 
Our own experience leads us to say that whenever we have found Drys- 
dale's corpuscle in the fluid from an abdominal cyst, it proved to be an 
ovarian cyst. On the other hand, in a few instances where we failed to 
find the corpuscle of Drysdale, the tumor still proved to be one of the 
ovary. We are therefore disposed to look upon Drysdale's corpuscle as 
an important and valuable auxiliary to the diagnosis of ovarian cysts, 
but by no means absolutely indispensable nor certain. We should cer- 
tainly give the corpuscle, when found, the benefit of the doubt in any 
case of abdominal cyst, and pronounce the latter to be ovarian if the 
corpuscle were found in its contents. 

In concluding a most comprehensive article " On the Diagnosis of 
Ovarian Cysts by Means of the Examination of the Contents," pub- 
lished in the American Journal of Obstetrics, vol. xv., 1882, Garri- 
gues says that Drysdale's granular ovarian cell is no cell, but the nucleus 
of an epithelial cell in a state of fatty degeneration. Since Bennett's 
corpuscles, Drysdale's corpuscles, nuclei with dark granules, and cho- 
lesterin have no diagnostic value, the most important elements in regard 
to diagnosis are columnar epithelial cells seen in side view. Their 
presence excludes all other tumors than those of the ovary, Fallopian 
tube, and' broad ligament (perhaps with the exception of a cyst of the 

1 The Microscope in its Application to Practical 3Iedicine, by Lionel S. Eeale, M. D., 
F. R. S., etc., 3d ed., p. 179. 



CAUSES. 681 

pancreas). Waldeyer was the first who pointed out the presence and 
diagnostic value of the columnar cells. A fluid clear as water, and 
containing very few histological elements, and without nuclei, with shin- 
ing granules (Drysdale's "ovarian cells"), maybe found in ovarian 
cysts, both true monocysts (hydrops folliculi) and multilocular cysts 
with ciliated epithelium. 

Causes. — Very little is positively known upon this subject. The 
predisposing causes which are generally admitted are the following : 

Age ; 

Childbearing ; 

Chlorosis ; 

Scrofulous diathesis ; 

Menstrual disorders ; 

Depreciation from poor living. 
It should be borne in mind that even as to some of these there are doubt 
and variance of opinion among gynecologists. 

The affection commonly shows itself during the period of ovarian 
activity, and very generally during that of the most vigorous activity. 
It is rare under twenty and over fifty, the most common period of its 
occurrence being between twenty and forty. It may, however, occur 
in infancy, and as late as eighty. The newborn foetus has even been 
found afflicted with an ovarian cyst, and several cases are on record in 
which children under four years of age have been successfully operated 
upon for this disease. 

As regards the age at which ovarian tumors are most likely to occur, 
the statistics compiled by Olshausen 1 from figures given by Peaslee, 
Wells, Koeberle, and Clay, in all 966 cases, sIioav that there were — 

Under 20 years 32 

Between 20 and 30 266 

" 30 and 40 298 

" 40 and 50 213 

Over 50 157 

The largest number of cases is thus seen to occur in the third decade 
of the childbearing period ; that is, at a time when ovarian activity 
is probably at its greatest height. With respect to the greater tend- 
ency of this disease to affect single or married women, tables furnished 
by Peaslee, Lee, Scanzoni, Wells, Nussbaum, and Olshausen show a 
proportion of 510 cases in single women to 730 married women, and 
would seem to indicate a greater disposition in favor of the unmar- 
ried condition. An examination of the years showing the greatest 
occurrence of the disease in single and married women respectively, 
taken from cases of Wells, Nussbaum, and Olshausen, gives the fol- 
low in <z result : 



<-> 



Under 20 vears, single, 23 ; married women ..... 

Between 20 and 29, " 151; " 63 

30 and 39," 82; " .... 153 

40 and 49, " SO; " 154 

Over 50, " 5(i: " 135 



Diseases of the Ovaries, 1877 



682 OVARIAN CYSTS. 

Although these last figures seem to show an increase in favor of the 
married woman after the thirtieth year, this deviation from the result 
of the previous table is easily explained by the fact that after that age 
many more women are married than single. The predisposition in 
favor of the single state still remains sufficiently prominent to merit 
attention. 

It was formerly supposed that ovarian tumors were much more fre- 
quent among women of the poorer classes than among the wealthy, but 
we can find no statistics in support of this belief, and our own experi- 
ence does not bear it out. The predisposing causes of cystic degen- 
eration of the ovary mentioned above are indeed so uncertain that, with 
the sole exception perhaps of chlorosis accompanied by more or less 
complete amenorrhoea — that is, the improper performance of the func- 
tion of ovulation — none can be said to be distinctly chargeable on 
undisputed evidence with the production of this disease. 

The uncertainty existing as to the exciting causes is even greater 
than this. All those influences which theoretically would be likely 
to excite cystic growth, as oophoritis, blows, checking of menstruation, 
excess of coition, libidinous desires without gratification, have been 
advanced by authors as scientific certainties. But proof is wanting, 
however plausible the theoretical reasoning appears, and they cannot 
in the present state of science be admitted. In the great majority of 
cases these tumors develop in women who have led rational and quiet 
lives, in whom no prejudicial influence can be discovered as having 
existed, and who have detected . the growth of the tumor when imag- 
ining themselves in very fair health. 

Certainly nothing can with safety be assumed beyond this, that it is 
probable that those influences which keep up and intensify ovarian con- 
gestion, and interfere with rupture of the follicles of De Graaf, tend to 
produce cystic and follicular degeneration. Kiwisch, Rokitansky, and 
Rindfleisch all agree in thinking it probable that inflammation affect- 
ing the walls of the vesicles has an influence on the production of the 
disease. 

Natural History of Ovarian Cysts. — Ovarian cystic tumors develop 
either by one or by a number of cysts. In the first case the cyst may 
become fully distended by fluid, reach a point where its growth ceases, 
and remain quiescent, only annoying the patient by the mechanical 
results of its presence and the apprehension that it may increase and 
create trouble. There are no grounds for doubting the evidence that 
such tumors may remain without increase for even forty or fifty years, 
but such cases are rare exceptions to a general rule. 

We now and then meet with pulmonary tuberculosis which goes on 
to the formation of a large cavity, and then for some unaccountable 
reason ceases to advance. The cavity, which is distinctly discernible, 
remains quiescent, and the patient may live for years. As this is an 
exception to a rule in the natural history of phthisis, so is the tardy 
course of ovarian dropsy just alluded to an exception to the usual 
course of that affection. The oligocystic tumor grows much more 
slowly than the polycystic, and this is the more marked as it ap- 
proaches the monocystic type. [I removed one which had been under 



SPONTANEOUS CURES. 683 

my own observation for nine years, and only at the end of this time 
did its existence affect the constitution. — T. Gr. T.] 

If its type be nmltilocular, the tumor advances more rapidly, cer- 
tainly, and uncontrollably than in the case just mentioned. The prog- 
nosis of ovarian dropsy not interfered with by art — and by this we 
mean surgical art, as medicine has no controlling or curative power in 
the disease — is always unfavorable. The average duration of the cases 
of both types is supposed by the best modern authorities to be about 
three years of life after the inception of the affection. 

Mr. Safford Lee has collected statistics 1 as to the duration of the 
disease in 123 cases not subjected to any curative surgical treatment: 

In 38 the duration was 1 year. 

25 " " 2 years. 

17 " " 3 " 

10 " " 4 " 

4 " " 5 " 

5 " " 6 " 

4 " " 7 " 

o a it n a 

17 " " .' .' '. 9 to 50 " 

From this it will be seen that out of 123 cases. 80 terminated within 
three, and 94 within five, years. At the same time that the fact must 
not be lost sight of that 17 out of 123 cases lasted over nine years, and 
that some, the number of which is not stated, terminated at the end of 
fifty, it must not be accepted as certain that these were cases of true 
ovarian cystoma. 

[I have removed an undoubted mutilocular ovarian cyst which had lasted, 
the evidence in favor of duration being medical and perfectly reliable, for 
twenty-three years ; another for twelve and a half years ; another for ten ; 
and another for nine years. — T. Gr. T.] 



Spontaneous Cures of Ovarian Cysts. — Sometimes nature effects a 
cure in one of the following ways : The cyst may discharge into the 
peritoneum and absorption occur. Of this accident t)r. Tilt has col- 
lected 71 cases, of which 30 recovered, 19 were improved, and 21 died. 
We have met with four instances of such rupture, two of which proved 
fatal by peritonitis. The cyst- walls may undergo calcareous degenera- 
tion, which checks advance. The cyst may discharge externally by the 
abdominal or dorsal surfaces, or into the rectum, bladder, vagina, or 
uterus by means of the Fallopian tubes. Instances of the last occur- 
rence are mentioned by Morgagni, Frank, Follin, and Boivin, and 
Richard records five cases. 

With reference to nature's power alone, or aided by absorbents, to 
remove the accumulated fluid, it would scarcely seem fair to the emi- 
nent authorities mentioned above, who have reported cases where this 

1 We have found ourselves compelled to reproduce this old table, simply because 
we could not discover anymore recent figures covering the same ground; which is 
probably due to the fact that of late years ovarian tumors have not been allowed to 
grow until they attained a certain size or killed the patient, but have been removed as 
soon as discovered. 



684 OVARIAN CYSTS. 

occurred, to deny its possibility ; but, in our opinion, the only ovarian 
cysts in which absorption of the contents which have escaped by rup- 
ture into the peritoneal cavity occurs, are those in which the fluid was 
thin, translucent, and free from granular matter, nucleated cells, and the 
other usual ingredients of ovarian poly cysts. That gelatinous and col- 
loid matter is not absorbed by the peritoneum has been proved to us 
by a number of instances in which we operated after rupture of an 
ovarian cyst had taken place some time before [in one case undoubt- 
edly a year. — P. F. M.], and the abdominal cavity was found filled with 
the unchanged ovarian fluid. 

Morbid Conditions to which Ovarian Cysts are Liable. — Inflamma- 
tion and suppuration of ovarian cysts may follow tapping or aspiration 
(it is scarcely likely to follow the former nowadays, since the practice 
of tapping has been substantially abandoned), or it may result from 
accidental causes, such as a bruise or an injury to the abdomen, or it 
may occur in consequence of a twisting of the pedicle of the tumor. 
The occurrence of pain, elevation of temperature, and general indispo- 
sition will lead to a suspicion of the true facts, the causes being perhaps 
obscure or discoverable on a careful inquiry into the history of the case. 
As a rule, when these symptoms occur in a patient in whom the dia- 
gnosis of ovarian cyst has been made, their nature is no longer in doubt, 
and the only true indication for treatment is immediate removal of the 
tumor by laparotomy. This was considered until within recent years 
quite a feat in the domain of ovariotomy, Keith having been the first 
to take the risk of cutting through an inflamed peritoneum for the pur- 
pose of removing an ovarian cyst which caused this inflammation. His 
result was so successful, the patient recovering as by a miracle after 
the operation, that his example was soon followed, and nearly every 
ovariotomist of experience now has cases of the kind to record. In 
nearly all the early cases the inflammation and suppuration of the cyst 
occurred as the result of tapping ; in the later, torsion of the pedicle 
has probably been the most common cause. It is safe to say that unless 
the general health of the patient has become too much debilitated, recov- 
ery from the operation under these circumstances is quite as probable as 
in uncomplicated cases. We have had the opportunity to operate on 
a number of such cases, and have saved some that seemed absolutely 
desperate. 

Peritonitis and adhesions may follow inflammation and suppuration 
of the cyst just mentioned or other accidental causes, the adhesions, of 
course, being secondary to the peritonitis. Adhesions, indeed, are by 
no means necessarily a sign of a preceding acute inflammation of the 
abdominal peritoneum, since they are found very commonly — are, 
indeed, one of the great unknown quantities to be expected and pro- 
vided for — in every ovariotomy. Simple contact between the surface 
of the ovarian tumor and the adjacent parietal and visceral peritoneum 
may by friction or serous agglutination result in more or less firm and 
extensive adhesions to the abdominal wall, intestines, and omentum. 
The diagnosis of these adhesions is by no means easy before opening 
the abdominal cavity. Their presence may be suspected by certain 
irregularities of growth and conformation of the tumor, by its greater 



TWISTING OF THE PEDICLE. 685 

proximity to one side of the abdominal cavity, by its failure to grow 
out of the pelvic cavity,, and by its apparent attachment to one part of 
the abdominal wall ; but nothing certain can be known until the hand 
is introduced into the abdominal cavity. The greater or lesser presence 
of adhesions between the cyst and the other pelvic and abdominal viscera 
has of course a very decided influence upon the ease or difficulty of the 
operation for the removal of the tumor, and consequently upon the 
chances of recovery. This applies particularly to adhesions between 
the intestines and the cyst, which in our opinion are the most unpleas- 
ant and difficult complications to be met with in ovariotomy. 

Twisting of the pedicle means the rotation upon its own axis of the 
tumor one or more times, and may not be followed by any unpleasant 
consequences so long as the torsion is not sufficiently sharp to constrict 
the large vessels running to the tumor, and interfere with the nutrition 
of the latter. This accident is limited usually to the smaller tumors ; 
that is, to such which, as they rise out of the pelvic cavity during their 
natural growth, can be turned upon their axis by the movements of the 
patient, or, as is most commonly the case, by the peristaltic action of 
the intestines. If a tumor has once reached so large a size that it fills 
the abdominal cavity and distends the abdominal walls, it is scarcely 
likely that it could be turned upon its axis sufficiently to twist its 
pedicle by its spontaneous motions, or indeed by any force applied 
either from within or without. The recognition of this occurrence is 
by no means a modern achievement, it having been described by Hardy 
in 1845, 1 Ribbentrop in 1846, Van Buren, 2 and carefully studied and 
analyzed by Rokitansky in the third edition of his textbook and in the 
Wiener Allgemeine Med. Zeitung in 1860. Its comparatively frequent 
occurrence and the dangers resulting from it are now fully recognized, 
although the exact manner in which the torsion takes place may be still 
a question to be answered only by an examination of each case. Usually 
only from a half to two twists are found in the pedicle, although we have 
seen from three to five, producing complete gangrene of the tumor (P. 
F. M.). In very rare cases, with an unusually thin pedicle, complete 
severance of the pedicle may take place in this manner, the separated 
cyst either becoming gangrenous and causing peritonitis by rupture or 
infection, or it may continue to live through adhesion to one of the 
neighboring organs, from which it thereafter draws its life. [I once 
produced a twisting of the pedicle of a multil ocular cyst, the nature of 
which was doubtful, by manipulations made for the purpose of perfect- 
ing a diagnosis. The subsequent operation showed a recent peritonitis, 
produced unquestionably by the twisting of the pedicle. I have ope- 
rated on nine cases of twisted pedicle, in one of which there was a 
double torsion of the pedicle, which was at least six inches long, the 
cyst being so rotten that I had to remove it from the abdominal cav- 
ity by passing my hand underneath and scooping it out. But all the 
patients, this one included, made uninterrupted recoveries. — V. F. M.] 
In such cases more or less fresh and extensive adhesions form an addi- 
tional difficulty to the operation. The diagnosis of twisted pedicle is 
usually not made until the ovarian cyst has been lifted out of the 

1 Lancet, April, 1845. '' New York Journal, March. 1850. 



686 OVARIAN CYSTS. 

abdominal cavity, although it may be suspected from the symptoms of 
inflammation and pain, which are unusual in ovarian cysts except as the 
result of some such complication. It is almost needless to say that the 
slightest suspicion of the occurrence of this accident calls for an imme- 
diate laparotomy. 

Intracystic Hemorrhage. — The presence of more or less fresh blood 
in an ovarian cyst can usually be accounted for only by the rupture of 
a blood-vessel in the walls of the cyst. This may be due to an inter- 
ference with the circulation, such as is produced by torsion of the ped- 
icle, or it may be caused by ulceration of the walls of one of the larger 
vessels, usually a vein running in the cyst-wall, or it may be a symp- 
tom of the malignant nature of the tumor. The diagnosis of the acci- 
dent can be made by a rapid increase in the size of the tumor, accom- 
panied by corresponding symptoms of general anaemia, and confirmed 
by the removal with the aspirator of bloody fluid showing under the 
microscope a very large quantity of red blood-corpuscles. While a few 
blood-corpuscles do occur in ovarian cysts occasionally, the color of the 
fluid is not influenced by their presence ; but whenever ovarian fluid 
has a blood-red color the probability is that this is due to a more or less 
recent intracystic hemorrhage. The occurrence is not one of special 
importance, except when the influence of the loss of blood upon the 
general system calls for speedy arrest of the hemorrhage by the removal 
of the bleeding cyst. 

Rupture of the Cyst. — In former days the contents of an ovarian 
cyst were supposed to be poisonous, or at least highly dangerous, to the 
abdominal peritoneum ; therefore the greatest care was exercised during 
ovariotomy to prevent any of the fluid escaping into the peritoneal cav- 
ity or remaining there, since it was assumed without question that it 
would always produce peritonitis, septicaemia, and death. This has 
been shown, however, not to be the case, since numerous instances are 
on record in which ovarian cysts have accidentally ruptured, sometimes 
almost unknown to their possessors, with no other evil consequences 
than a comparatively slight peritonitis, from which the patient recov- 
ered in due time. The amount of irritation produced upon the perito- 
neum by the cyst contents depends, of course, a great deal upon the 
nature of those contents : the thicker and less capable of absorption is 
the effused cyst-fluid, the more acute, more serious, and more lasting 
is the peritonitis which it excites ; and undoubtedly in the majority of 
cases a chronic peritonitis is established which eventually results in the 
distension of the abdomen by additional ascitic fluid, the condition 
being then taken for ascites from some unknown cause. If, then, a 
patient falls into the hands of a laparotomist, her abdomen is opened, 
probably with the view of making the diagnosis, and to the surprise of 
the operator is found to be filled with the peculiar viscid or colloid 
material characteristic of ovarian cysts, and the ruptured cyst is easily 
detected and removed. The better the health of the patient at the 
time of this operation, the greater of course the chances for her recov- 
ery. We have operated on quite a number of cases of this kind, and 
have had some surprising results, even when the rupture had taken 
place, so far as we could ascertain, a number of months before. The 



COM PLICA TIONS. 687 

thorough cleansing of the abdominal cavity by irrigation, and usually 
the employment of the drainage-tube, are important features in the 
operation. 

A number of cases are on record in which ovarian cysts have allowed 
their contents to escape into the abdominal cavity through compara- 
tively small openings at repeated intervals, each such occurrence being 
characterized by general abdominal pain, more or less distinct symp- 
toms of peritonitis, and diminution in the size of the abdomen. The 
mystery in these cases — for even to the most experienced such an acci- 
dent is not a frequent occurrence and not always easy of explanation — 
is cleared up when finally laparotomy is performed, and an ovarian cyst 
is removed in the wall of which is found an opening permitting the 
passage of a large knitting-needle or even a pencil, the cyst-walls being 
flaccid and the abdominal cavity containing ovarian fluid. Usually the 
abdominal peritoneum shows signs of a more or less recent inflammatory 
process. If the patient has borne the repeated emptying of the cyst 
contents into the peritoneal cavity fairly well, her chances of recovery 
from the removal of the cyst are no worse than after any ordinary 
ovariotomy. 

Conditions likely to Complicate Ovarian Cysts. — 

Pregnancy ; 

Fibroids of the uterus ; 

Cancer of the uterus ; 

Diseases of the kidney ; 

i Diseases of the liver, heart, and lungs ; 

Compression of the ureters ; 

Elevation of the bladder. 
Pregnancy as a complication of ovarian cysts is by no means a rare 
occurrence. That it may occur w T hen only one ovary is diseased is self- 
apparent, but that it does take place when both ovaries have undergone 
cystic degeneration, even to the development of tumors of more or less 
pronounced size, seems rather strange. Still, some cases are on record 
in w T hich this has taken place, one of the most remarkable being prob- 
ably that witnessed by both of us (the patient being under Munde's 
care and operated by him) in which both ovaries had undergone cystic 
and dermoid degeneration to such an extent that apparently nothing- 
was left of the normal structure of the organs, and still pregnancy 
occurred and went on to the fifth month, being terminated by the irri- 
tation produced by the removal of the ovarian tumors. The occur- 
rence of pregnancy during the existence of an ovarian cyst so far com- 
plicates the treatment and prognosis of the latter in that the larger the 
uterus grows in advancing pregnancy, the more will the uterus and the 
ovarian tumor together interfere with the comfort and general health 
of the patient. Both tumors together — one of which, the uterus, is at 
least growing steadily — will of course enlarge the abdomen very much 
more than either one separately. The pressure upon the kidneys, the 
liver, intestines, and secondarily the lungs and heart, would necessarily 
therefore be much greater, and the call for relief more urgent, than in 
either normal pregnancy or ordinary cystic disease. We do not mean 
to say that the ovarian tumor grows during pregnancy in proportion to 

44 



688 OVARIAN CYSTS. 

the increase in size of the uterus ; on the contrary, we think that the 
compression exerted upon the ovarian tumor by the constantly increas- 
ing pregnant uterus rather retards the growth of the former ; still, the 
two together are very apt to affect the patient in such a manner as to 
require more or less speedy relief. This may be effected either by 
emptying the uterus — that is, inducing abortion or premature labor — 
or by removing the ovarian tumor by abdominal section. It is usually 
advisable to endeavor to save the child, if in any way possible, by allow- 
ing the pregnancy to go on until the foetus is viable ; that is, up to the 
end of the seventh month. If the condition of the patient permits, the 
tumor may be removed by laparotomy as soon as she has recovered 
from the puerperal state. Where, however, the ovarian tumor grows 
more rapidly than the pregnant uterus, or is situated between the latter 
and the pelvic outlet so as to interfere with the normal expulsion of the 
child at term, an early removal of the ovarian tumor is indicated, even 
at the expense of a possible interruption of the pregnancy. The ope- 
ration of ovariotomy during pregnancy has been proved by numerous 
statistics to be very little more dangerous than when performed under 
usual circumstances. Olshausen in 1886 reports a total of 82 opera- 
tions with 74 recoveries, the majority of those recovering carrying their 
children to term. The question as to whether the ovarian tumor should 
be removed and the pregnancy allowed to go to term, or the pregnancy 
be interrupted and the operation of the ovarian tumor be postponed to 
a later date, depends entirely upon the predominance of the pregnancy 
or the tumor in each given case. 

Fibroids of the Uterus may complicate cystic disease of the ovary, 
but exert very little influence either upon the progress of the cyst or 
upon the treatment and prognosis. 

Cancer of the Uterus, cervix or body, may occur at the same time 
with cystic degeneration of one or both ovaries. If the cancer were 
radically incurable, we do not think we would advise subjecting the 
patient to the danger, however slight, of an ovariotomy, since in all 
probability the cancerous affection would kill her before that of the 
ovary. Only when it seems possible to eradicate the cancerous disease, 
so as to give hopes of a perfect cure, would the removal of the ovarian 
tumor at the same or a later time seem justifiable. Of course, if we 
were removing a cancerous uterus per vaginam, and chance to discover 
the. existence of an ovarian cyst of moderate dimensions at the same 
time, we should endeavor to do our duty toward the patient by remov- 
ing both diseased organs at the same sitting. 

Diseases of the Kidneys, Liver, Heart, and Lungs are not at all 
uncommon as complications of cystic degeneration of the ovaries. 
With the exception of disease of the kidneys, they are usually due 
to causes in no way dependent upon the enlargement of the ovaries ; 
but the kidneys are very liable to become degenerated in consequence 
of the pressure produced on the ureters by the constantly increasing 
ovarian tumor, chiefly if the development of the latter is intralig- 
amentous and extra-peritoneal ; that is to say, between the layers of 
the broad ligament. The ureter may thus become obstructed on the 



METHODS IN WHICH DEATH IS PRODUCED. 689 

affected side ; distension -of its canal above the point of obstruction 
and of the pelvis of the kidney may ensue, with inflammation and 
suppuration of both parts. Naturally, an inflammatory and suppu- 
rative degeneration of the kidney itself follows, which may attain 
a sufficient degree to cause death. That this complication is not 
more frequent in ovarian tumors is a matter of surprise, to be 
accounted for only by the tendency of the tumors to grow toward the 
abdominal wall and away from the vertebral column. The larger an 
ovarian tumor grows, the more of course will it interfere with the cir- 
culation in the abdominal viscera, particularly with the return of venous 
blood to the heart. (Edema of the lower extremities, with the occa- 
sional inflammation of the larger veins, is therefore not a very uncom- 
mon occurrence in large ovarian tumors. 

The bladder is occasionally carried away from its normal position 
up into the abdominal cavity by becoming attached to the anterior 
surface of an ovarian tumor, or by being pushed up out of the pelvis 
through the development into the pelvic cavity of a cyst of the ovary. 
[I have recently seen such a case in which a dermoid tumor of the left 
ovary, the right being also diseased in the same manner, pushed up the 
bladder, so that it narrowly escaped injury on opening the peritoneal 
cavity. On removal of the tumor the bladder dropped back to its 
normal position. — P. F. M.] If this elevation of the bladder is 
unsuspected, it is easy to understand how it may be opened by a hasty 
incision through the abdominal wall. 

Of course an inflammation of the peritoneum with adhesions between 
the cyst and the adjoining viscera, a pleurisy or pneumonia, a gastritis, 
a gastro-intestinal catarrh, may complicate the presence of an ovarian 
cyst, but they do not necessarily depend upon its existence, and, once 
recovered from, have no bearing upon the further development of the 
ovarian disease, with the exception of the peritonitis, which may have 
left adhesions more or less extensive, and therefore of considerable 
interest to the expectant operator. A rise of temperature complicating 
an ovarian cyst, unless distinctly referable to inflammation of that organ 
or to peritonitis, must be due to some cause which might occur at any 
time entirely irrespective of ovarian disease. The possibility of suppu- 
ration of the cyst, peritonitis, and septic infection should always be 
borne in mind in such cases as possibly indicating speedy operative 
interference. 

Methods in which Death is Produced. — There are several modes in 
which ovarian dropsy produces its usual fatal result when uninterfered 
with by surgical means : 

1st. A cyst may rupture and produce peritonitis, either before or 
after suppurative inflammation of its walls. 

2d. Inflammation of the cyst-wall may result in the filling of the 
cyst with pus, which produces septic infection and in time exhaustion 
and death. 

3d. Death of the cyst may occur from twisting or rupture of the 
pedicle and cause septicaemia. 

4th. Prolonged interference with the functions of nutrition and 
respiration may sap the powers of life. 



690 OVARIAN CYSTS. 

5th. Acute or chronic peritonitis may either cause rapid death or 
gradual exhaustion. 

6th. Fatal hemorrhage may occur into the cyst. 

7th. Finally, from the combined depreciating influences of this 
condition, gradual or sudden prostration of strength may close the 
scene by death. 

Every one having charge of a case of ovarian tumor should recol- 
lect that often the only hope of saving life, threatened by the accidents 
here recorded, consist in an immediate resort to ovariotomy. Even 
acute peritonitis has been thus cut short, and patients with a tem- 
perature of 105° from suppuration of the sac have been saved. 

We now approach the important subject of symptomatology of 
ovarian cysts, and their differentiation from other morbid conditions 
met with in the abdomen. 

Differentiation.— The faculty of distinguishing between different 
forms of abdominal tumors in the female is one acquired only by 
long years of experience, and after many failures. The distinctive 
points of many of these tumors are so obscure, and so dependent upon 
the sense of touch of each individual examiner, that no absolutely 
certain rules can be laid down for diagnosis and no infallible pre- 
cautions be advised to prevent error. In each case the symptoms 
have to be carefully considered, reviewed, weighed against each other, 
and then by a gradual process of elimination the probable diagnosis 
must be narrowed down to as close limits as possible. The justifica- 
tion for these remarks will be found in the fact that pregnancy, uterine 
fibroids, distended - bladder, cysts of other abdominal organs, adipose 
development of the abdominal walls, distension of the abdomen by 
gas, etc., have all been mistaken on repeated occasions, and often by 
really competent examiners, for ovarian tumors. We ourselves have 
more than once been at a loss to determine whether an abdominal 
tumor was one of the ovary, which was the most natural to suspect, or 
of the uterus, kidney, spleen, liver, or omentum ; and mistakes of the 
most flagrant nature have been made by men standing high in the 
records of obstetrical and gynecological science. For this reason we 
desire to devote some special attention to the discussion of the differ- 
entiation between ovarian and other tumors in the abdomen which 
resemble or simulate them. 

Solid Abdomixal Tumors resembling Ovarian Tumors. — 
Pedieulated Fibroids. — It is usually a matter of the greatest difficulty 
to decide whether a tumor apparently attached to the uterus by a 
slender, long pedicle, said tumor being freely movable in the abdominal 
cavity, being very little if at all tender to the touch, having a semi- 
soft, elastic feel, and having grown but slowly, is a pedieulated uterine 
fibroid or a fibroma of the ovary. "We really know of no one sign or 
series of signs which would enable us to make a positive diagnosis in 
such a case. The uterus is not involved in either instance ; its length 
remains normal ; it is not moved when either the pedieulated or the 
ovarian fibroid is pushed about ; and apparently there is no connection 
between the tumor and the uterus. The only symptom which might 



DIFFERENTIA TION. 691 

help would be that an ovarian fibroid is likely to cause more pain with 
and without pressure than a pediculated fibroid of the uterus. 

Solid Tumors of the Spleen may simulate solid tumors of the ovary, 
because the former frequently extend down into the abdominal, and 
even into the pelvic, cavity, so that they can be reached through the 
vaginal vault. The uterus and ovaries may be more or less masked to 
the examining finger by the presence of this abdominal growth, and 
therefore the ovaries cannot be detected. If this were possible, of 
course they would be at once eliminated from consideration. The 
peculiar sharp upper border of the spleen, the absence of that organ 
from its normal position, the history of malaria or leucocythsemic dis- 
ease, would of course help to turn the scale in favor of splenic disease, 
but the diagnosis may often be exceedingly puzzling. Thus Ave both 
saw a case a year ago (the patient being under Dr. Munde's care, 
who asked Dr. Thomas to see her with him) where we agreed that the 
tumor had the outward appearance and feel of an enlarged spleen (nor- 
mal splenic dulness being indistinct), but that an exploratory laparot- 
omy was indicated. This was done, and the tumor found to be a mul- 
tilocular ovarian cyst, which was removed and the patient recovered. 

Displaced Kidney. — It would hardly seem possible that a displaced 
kidney should be mistaken for an ovarian tumor, but still this has been 
done in one case by Mundd, who found what he considered to be an 
adherent small ovarian tumor in Douglas's pouch, and on removing it 
by laparotomy discovered it to be the displaced left kidney. For- 
tunately, the patient recovered. In another case recently seen by a 
physician of this city the tumor was found above the umbilicus on the 
left side, was freely movable, was about the size of a cocoanut, and 
extremely tender ; it was pronounced to be the displaced and enlarged 
left kidney. When Munde saw the case several weeks later the 
tumor had dropped below the umbilicus, and was pronounced by 
him to be an ovarian cyst, which diagnosis he verified by laparotomy. 

Tumors of the Anterior Abdominal Wall [Desmoids) are usually 
of a fibrous or sarcomatous nature. They should in reality never be 
mistaken for intra-abdominal growths, but they are often so closely 
attached to the abdominal peritoneum that it is almost impossible to 
say, until they have been cut down upon, whether they are extra- or 
intra-peritoneal. Of course this difficulty of diagnosis is enhanced by 
the presence of a large amount of adipose tissue. 

Abdominal and Pelvic Cysts resembling Ovarian Cysts. — 
Cysts of the Broad Ligaments may at times so closely resemble ova- 
rian cysts that the differential diagnosis is absolutely impossible except 
by the examination of the cyst contents. The fluid in cysts of the 
broad ligament is always limpid, clear, and transparent as spring- 
water, containing no microscopical elements whatever except a few 
columnar epithelia. Very rarely such limpid fluid is found in ovarian 
monocysts, but then usually the granular corpuscle of Drysdale settles the 
diagnosis. Like the ovarian cysts which develop between the layers of 
the broad ligament, the cysts of the broad ligament probably spring from 
the organ of Rosenmiiller, the so-called parovarium, develop downward 
into the pelvic cavity between the layers of the broad 



692 OVARIAN CYSTS. 

usually only when they have reached the bottom of the pelvic cavity 
extend downward into the abdominal cavity, dissecting up before them 
the parietal layer of the peritoneum. They are therefore always extra- 
peritoneal, no matter how much they may project into the abdominal 
cavity or cause the anterior abdominal wall to protrude. The chief 
point of diagnosis is the ease with which the cyst is felt per vaginam, 
the de*pth to which it reaches in the pelvic cavity, often extending as 
low as, or even lower than, the level of the external os, the immobility of 
the cyst, the absence of the usual ovarian cachexia, the slow^ growth of 
the cyst, and its comparatively slight dimensions. These cysts indeed 
seldom grow larger than an adult head; still, cases are on record in 
which they attained the size of the pregnant uterus at term, and 
Munde has operated on one which contained thirty-eight pints of fluid. 
The older operators favored the mere puncture of these cysts, either 
per vaginam or through the abdominal walls, evacuation of the contents, 
and trusted in the efforts of nature to effect contraction of the cysts. 
It was thought that in this way these cysts could be cured by simple 
evacuation of the contents, but later experiences have taught that 
even cysts of the broad ligament are liable to refill, and that the only 
permanent cure for them is to remove them in the same manner as is 
done with intra-ligamentous ovarian cysts ; that is, cysts of the ovary 
which grow down between the layers of the broad ligament, instead of 
developing, as ovarian cysts usually do, toward the abdominal cavity. 
This can be done either by enucleating the whole sac from its socket 
and sewing the edges of the wound in the broad ligament to the abdomi- 
nal incision, or else by sewing sac and broad ligament to the abdominal 
incision without enucleation of the cyst. The pocket thus left behind 
gradually shrinks and heals by granulation. 

Uterine Fibro- Cysts. — There is probably no more difficult diagnosis 
to make in the region of abdominal tumors than that between a fibro- 
cyst of the uterus and a multilocular ovarian tumor. The history as to 
length of growth, original position of the tumor, amount of pain, etc. 
is usually very indefinite. If anything, the fibro-cyst has taken longer 
time to grow than the ovarian cyst ; then an important sign has 
always seemed to us to be that of the comparative absence of constitu- 
tional derangement in uterine fibro-cysts, whereas in ovarian polycysts 
of the same size it was very marked. We would decidedly advise that 
particular attention be paid to this symptom, the neglect of which has 
in two instances resulted in our (P. F. M.) operating on a uterine fibro- 
cyst which we would certainly have let alone if we had made the correct 
diagnosis. The examination of the fluid removed by aspiration is of 
very little diagnostic value. The length of the uterine cavity likewise 
does not always afford much assistance, since in many fibro-cysts the 
body of the organ itself is in no way involved. The most experienced 
and careful examiners and operators have made mistakes in this particu- 
lar quarter. 

Encysted Peritoneal Dropsy. — As a result of general peritonitis, 
localized accumulations of fluid are occasionally found, which simu- 
late an actual cyst in consequence of agglutination of the intestines 
around the effusion. If these are situated near the brim of the pelvis, 



DIFFERENTIATION. 693 

they may very readily simulate an ovarian cyst. Examination of the 
fluid removed by aspiration, which will reveal the presence of pus- 
corpuscles perhaps, or possibly the absence of any organic elements 
except flat epithelial cells from the peritoneum, and the history, will 
usually protect the examiner against an erroneous diagnosis. 

Renal, Hepatic, and Splenic Cysts. — As a general rule, all cysts or 
tumors which grow from above the umbilicus downward toward the 
pelvic brim push the intestines before them, and there will usually be a 
zone of resonant percussion sound between the symphysis pubis and 
the lower border of the tumor. This is exactly the opposite from what 
occurs in ovarian tumors, which, growing from below upward, push the 
intestines before them in the direction of the diaphragm. Only when 
a coil of intestine becomes accidentally adherent to the anterior surface 
of an ovarian cyst will resonant percussion sound ever be found between 
the symphysis pubis and the upper border of the cyst. Besides, it must 
be remembered that cysts of the spleen and liver originate and spread 
downward from the left and right hypochondria respectively — that the 
absence of these organs in their normal position is essential to the pos- 
sibility of the abdominal tumor being of that character. Moreover, 
the peculiar shape of the spleen and liver will aid in the diagnosis. 

Renal cysts very rarely extend as far down as the pelvic cavity 
(although we must not forget that a displaced kidney may be found 
even at the bottom of that cavity ; see Munde's case), and Polk removed 
a kidney situated at about the level of the pelvic brim which he mis- 
took for a small ovarian tumor. 

Examination of the urine will usually be of little service in deter- 
mining the presence of renal cysts. The examination of the contents 
of the cyst, however, removed by aspiration, will probably result in a 
correct diagnosis, since probably urea and renal epithelia will be found. 
In a case of supposed ovarian cyst which Munde saw some twelve years 
ago, but in which the correctness of the diagnosis was questioned in 
consequence of the exceedingly slow growth of the apparently mono- 
cystic tumor and of its attachment to the right hypochondrium, exami- 
nation of the aspirated fluid showed bile and distinct liver-cells, at once 
proclaiming the cyst to be one of the liver. Munde referred the case 
to Dr. Thomas at his clinic, who confirmed the diagnosis, and also con- 
curred in Munde's decision not to operate. This decision was differed 
from by her physician in the country, and the patient promptly died 
after the operation. 

Parasitic Cysts. — These are usually the result of the entrance into 
the system of the Cysticercus cellulosce, both the parent and offspring 
of the Tamia solium. They develop either in the liver, spleen, pelvic 
cellular tissues, or very rarely in the substance of the uterus itself. 
They may attain great size and grow very rapidly. Their diagnosis is 
usually entirely obscure until some of the aspirated fluid has boon placed 
under the microscope, when the peculiar scolices of the parasite at once 
reveal the diagnosis. 

Hydrosalpinx. — A differentiation between an accumulation of serum 
in the Fallopian tube and an ovarian cyst will become necessary only 
in the case of small monocystic tumors of the ovary, llydro-salpinx 



694 OVARIAN CYSTS. 

very seldom attains dimensions larger than that of a pint measure. It 
usually remains loose, or perhaps attached in the bottom of Douglas's 
pouch. It is unilocular, fluctuating, not particularly tender, and the 
history is more or less obscure. Aspiration per vaginam will usually 
make the diagnosis, since the fluid from hydro-salpinx will present abso- 
lutely negative results under the microscope, whereas in the ovarian 
cyst usually, but not always, the granular corpuscle will be found. 
Besides, in hydro-salpinx columnar epithelium may possibly settle the 
diagnosis in favor of the tubal affection. 

Cysts of the Omentum, Mesocolon, and Pancreas. — These forma- 
tions are of such rare occurrence that but very few instances are on 
record, and no positive diagnostic points can be given for them except 
by means of examination of the fluid removed by aspiration. Munde 
saw a cyst of the mesocolon which he considered to be an ovarian cyst, 
since bimanually he thought he could clearly trace its attachment to the 
left broad ligament. The same view was entertained by Drs. T. A. 
Emmet and Robert Watts, the latter of whom finally secured the case 
for operation, and discovered the error of diagnosis too late to save the 
patient, who died from the operation. 

Tubercular Peritonitis. — This disease is usually not discovered until 
the opening of the abdominal cavity made for the purpose of arriving 
at a diagnosis or for the removal of a supposed ovarian cyst or tubal 
disease shows the intestines and abdominal peritoneum studded over 
with yellow dots, which at once make clear the character of the disease. 
The indication for the operation will usually have been the detection 
of a more or less defined abdominal tumor, commonly felt on one side 
or the other in the ovarian region, and supposed therefore to be an 
ovarian or tubal cyst. In reality, it is an agglutination of the intes- 
tines, with the encapsulation of a certain amount of fluid, in this 
respect resembling encysted dropsy, already referred to. Of course, 
tubercular disease of the tube and ovary may be the original site of 
the disease, the germs having probably entered through the vagino- 
uterine canal. Exactly how to differentiate between localized agglu- 
tination of intestines and encapsulated fluid in tubercular peritonitis 
and small ovarian cysts we are at a loss to determine. We would 
merely beg our readers to bear in mind the comparative frequency of 
this disease, especially in the female sex, and the possibility that an 
obscure case of abdominal or suprapelvic cyst may be of this nature. 
The combination of tubercular disease of other organs must by no 
means be accepted as a guide for diagnosis in such cases, since usually 
the tubercular disease of the peritoneal cavity comes on by itself insid- 
iously, and may even turn out fatally without involving any other organ 
of the body. 

Cysts connected ivith the Spinal Cord. — A very few instances are on 
record in which a congenital separation of the lower portion of the spinal 
cord, a hyclrorhachis, has allowed an amount of fluid to gradually push 
before it the spinal meninges and encroach upon the pelvic cavity. 
Usually the direction of this cystic distension is backward toward the 
skin, forming the well-known and not uncommon condition called spina 
bifida ; but if this should grow toward the pelvic cavity, it is evident 



DIFFERENTIA T10N. 6 9 5 

such a cyst might simulate a deep-seated ovarian or broad-ligament cyst, 
and that the diagnosis might be attended with some difficulty. The 
discovery of the cleft in the spinal column will of course clear up the case 
at once. Emmet described a most typical instance of this deformity 
which entered his service in the Woman's Hospital in 1870 (see Amer- 
ican Journal of Obstetrics, February, 1871). The diagnosis was only 
made at the autopsy. 

Ascites. — Strange as it may seem, a free effusion of serous fluid into 
the abdominal cavity has been mistaken for an ovarian cyst in more 
than one instance. Only a rather careless examination or a precon- 
ceived diagnosis can account for such a mistake ; and still Munde saw 
Scanzoni and Linhardt, both professors at the University at Wurzburg, 
open an abdominal cavity for what they supposed to be an ovarian cyst, 
that being the diagnosis with which the patient had been sent to them 
(this was in 1868), only to find, to their great surprise and mortifica- 
tion, that it was a simple case of ascites due to chronic peritonitis. The 
patient fortunately recovered. The greater flatness of the abdomen, the 
change of position of the fluid as the patient turns from side to side, 
together with corresponding change of the resonant percussion sound, 
the uniform transmission of the wave of fluctuation from side to side, 
the entire absence of any encysted mass or of a circumscribed tumor in 
the abdominal cavity, and the discovery of a probable cause for the 
abdominal dropsy, will usually enable the physician to avoid making 
this, generally inexcusable, mistake. 

Distended Urinary Bladder. — To mistake the distended bladder for 
an ovarian cyst is even a far greater blunder than applies to ascites, 
and still it has been done. This mistake can be made only by accept- 
ing the statements of the nurses or patients that the bladder has been 
regularly emptied, when the dribbling from that viscus w T as merely the 
overflow from the excessively distended organ. The introduction of a 
catheter will of course at once reveal the presence of an enormous quan- 
tity of urine, on the removal of which the supposed tumor is found to 
have disappeared. 

Pregnancy. — It is not necessary for us to enter into any details as 
to the differential diagnosis between ovarian tumors and pregnancy. 
That such a mistake has been made can unfortunately not be denied, 
for the pregnant uterus has even been opened by operators supposed to 
be fairly intelligent, under the impression that they had to deal with an 
ovarian tumor. The only cases in which we can imagine the possibility 
of such an error are those in which enormous thickness of the abdomi- 
nal walls prevented the foetal heart from being heard and the foetal 
parts from being felt on palpation, and in which the history was of S(> 
doubtful and misleading a character that the existence of pregnancy 
was not even suspected. That this may occur cannot be denied by any 
practitioner who lias had an opportunity to see many cases of doubtful 
abdominal enlargement. A combination of pregnancy and ovarian cyst 
will naturally render the diagnosis still more obscure. 

Pseudo-Cysts. — Under this heading we include several conditions 
which simulate abdominal cysts, but which in reality are no cysts or 
tumors at all. Foremost among these is the distension o\' the abdominal 



6 ( JQ OVARIAN CYSTS. 

cavity by gas in the intestines. This symptom is usually not constant, 
and its true character can generally be suspected if the patient admits 
that the size of her abdomen is not always uniform, sometimes being 
larger and at other times smaller. Pendulous abdomen and an exces- 
sive development of adipose tissue in the abdominal wall may likewise 
simulate an ovarian tumor. "We have seen numerous cases sent to us 
by their physicians with the diagnosis of abdominal tumor, which on 
putting the patients on their back, removing the clothes, and thus relax- 
ing abdominal pressure, proved to be nothing more than the trifling 
anomalies just mentioned. The uniform area of resonant percussion 
sound in distension by gas, the possibility of flattening down of the 
abdomen in the dorsal position, and the possibility of lifting up five or 
six inches of fat from the abdominal muscles will usually settle the dia- 
gnosis. 

Fecal Tumor (Coprostasis). — Strange as it may seem, an accumula- 
tion of fecal matter in the intestine has been more than once mistaken 
for an ovarian tumor. Such accumulations are usually not very large, 
perhaps varying from the size of the fist to that of a cocoanut, and 
their appearance and feel are often exceedingly deceptive, especially 
when incorrect and misleading statements are made by the patient or 
her physician as to the condition of the bowels, which are pronounced 
to be perfectly regular. We have seen small fecal accumulations which 
were clearly defined in outline, perfectly movable, not particularly ten- 
der, and situated on one or both sides of the lower part of the abdom- 
inal cavity, pronounced to be small ovarian tumors or pediculated fibroids 
of the uterus ; and Munde remembers one case which occurred in the 
Julius Hospital in TViirzburg, in the service of the late Prof. Bamberger, 
the great authority on internal medicine, since deceased as professor at 
Vienna, where a woman was presented to the class with a large semi- 
solid ovarian tumor. Nobody doubted the diagnosis, but at the autopsy 
the tumor was found to be an enormous accumulation of pultaceous fecal 
matter which filled nearly the whole abdominal cavity. Through the 
centre of this mass ran a channel which accounted for the regular fluid 
evacuations, and explained why the attending physicians had never 
thought of fecal impaction. The importance of carefully eliminating 
the possibility of this occurrence — indeed, of assuring one's self against 
the possibility of a mistake by seeing that laxatives are administered 
before a conclusive examination is made — should be borne in mind in 
deciding on the diagnosis of doubtful cases. 

Symptoms. — During the earlier periods of the development of ovarian 
cysts very few symptoms ordinarily show themselves. As enlargement 
goes on, the patient becomes struck by the fact that her abdomen has 
increased in size, and if both ovaries be affected menstruation some- 
times ceases, and she may imagine she has become pregnant. Pressure 
of the small but increasing; tumor will sometimes create drag-gins; sensa- 
tions about the pelvis, irritability of the bladder, and. if the growth 
occupy the retro-uterine space, as it often does, pain in the back. This 
is. however, by no means all the inconvenience which may be expe- 
rienced. A small, movable cyst, which may be pushed about in the 
abdomen, will sometimes cause severe pain. [In one such case which I 



SYMPTOMS. 697 

saw with Dr. Noeggerath, the account of which is published in Dr. 
Atlee's work on the Ovaries, ovariotomy was necessitated, when the 
cyst was no larger than a cocoanut, by excessive pain. — T. G. T.] [I 
recently met with a similar case, the cyst being unilocular, non-adhe- 
rent, with a long pedicle. The pressure produced on the abdominal 
viscera by the very movable cyst seemed to be the only explanation of 
the pain, which ceased after the operation. — P. F. M.] 

As the tumor grows and fills the abdomen, rising above the navel, a 
sense of distension is complained of, dyspnoea begins to show itself upon 
exertion, the patient feels more feeble than usual, and slight emaciation 
is observed. As it increases and begins to press upon the large viscera 
beneath the diaphragm, these symptoms increase, and the patient's face 
wears a peculiar expression, which has been styled by Spencer Wells the 
"facies ovariana.") This is created by an absorption of adipose tissue, 
an exaggeration of the natural furrows of the face, and an expression 
of anxiety and apprehension. To one who has studied this expression 
an imperfect description such as this will recall it ; but to one who has 
not become clinically familiar with it it is impossible to conve} 7 a clear 
conception of it. To these symptoms the mammary and gastric symp- 
toms of pregnancy sometimes, though rarely, add themselves. 

Pressure upon the kidneys creates congestion of these organs, and 
scanty secretion is a common result. Occasional attacks of localized 
peritonitis are by no means rare, and hence in many cases ascites 
becomes a complication of the affection. 

As the decadence of strength, the emaciation, and the impovei'ish- 
ment of the blood incident to this grave disorder increase with time, 
digestive and intestinal disorders show themselves, oedema of the feet 
and legs occurs, great feebleness appears, and the patient dies from 
progressive exhaustion. 

A summary of the rational signs which may arise in consequence of 
ovarian cysts from the commencement of their growth to full develop- 
ment may thus be given : Irritability of the bladder, dysmenorrhoea, 
constipation, hemorrhoids, pelvic pains of neuralgic character, symp- 
toms of pregnancy, scanty urinary secretion, intestinal and digestive 
disorder, deranged respiratory function, peculiar facies, emaciation, 
oedema, venous distension on surface, ascites, vomiting, diarrhoea, car- 
diac irregularity, aphthous stomatitis, and hectic. In cases advanced 
in the last stage all the last of these may show themselves, and in early 
cases all the first mentioned ; but in many instances some of the most 
prominent of these signs are entirely wanting. 

Physical Signs. — The symptoms thus far enumerated are never suf- 
ficient for diagnosis. They are usually only sufficient to suggest phys- 
ical examination, by which reliable signs will probably be discovered 
and the diagnosis be made complete. 

The physical signs of ovarian cysts are, therefore, of the greatest 
importance, and the full capacity of physical exploration should in 
every case be developed, for to it we must look for answers to the fol- 
lowing questions : 

1st. Does a tumor exist? 



698 OVARIAN CYSTS. 

Does a Tumor Exist f — To decide this question the patient should 
be placed upon her back upon a flat, resisting surface, the abdomen 
uncovered, all constriction removed from the waist, and the knees drawn 
up so as to relax the abdominal muscles. It is of primary importance 
that she should be calm and give herself up to the examination in the 
full desire of aiding the physician in arriving at a diagnosis. In some 
cases the patient from nervousness, in some from pain created by pres- 
sure, and in others from a desire to mislead and deceive, will not be 
able or willing to do this, but by suddenly contracting the abdominal 
walls will place a serious, perhaps insurmountable, obstacle in his way. 
Under such circumstances ether should be employed as an anaesthetic 
and full investigation made. The abdominal muscles being entirely 
relaxed, careful palpation and deep, steady, and prolonged pressure 
should be made by both hands over the whole abdomen downward 
toward the spine, and especially over the pelvic region. By this means 
a more or less resisting mass may be discovered, which produces an 
abdominal enlargement visible upon inspection. 

Thus far, very little has been learned ; merely that an abnormal 
enlargement exists in the abdomen. It may not deserve the sig- 
nificant name of tumor, but be clue to one of these states : 

1st. Abnormal thickness of abdominal walls ; 

2d. Tonic spasm of abdominal muscles ; 

3d. Intestinal distension ; 

4th. Distension of urinary bladder ; 

oth. Pregnancy. 
With care and caution each of these conditions may usually be elim- 
inated by means which we shall soon consider. A neglect of such 
means has often resulted in great and needless alarm to patients, and 
a painfully humiliating and often ludicrous exposure of the practi- 
tioner. 

It having been now decided that the patient has an abdominal tumor 
— or, in other words, an abdominal swelling due to a morbific cause of 
serious nature — it next becomes important to decide whether it be 
ovarian or not. 

Is the Tumor Ovarian? — It has been already stated that any 
abdominal tumor may, unless careful means of differentiation are 
adopted, be confounded with ovarian growths. The truth of this 
will be appreciated by reference to the valuable tables of Dr. John 
Clay, the translator of Kiwisch on the Ovaries. He has collected 23 
cases of attempted ovariotomy in which the operation was abandoned 
because the tumor proved not to be ovarian. 1 The tumors were of the 
following characters : 

12 were uterine ; 
2 " omental ; 

2 " results of chronic peritonitis ; 
2 " not discoverable ; 

1 We have retained this table partly as a curiosity, and partly as a warning to the 
operators of the present day not to forget the possibility of an error in the diagnosis 
of abdominal and pelvic tumors. There is no ovariotomist living who will not be 
compelled to admit that he has made at least one mistaken diagnosis in such a case. 



SYMPTOMS. 699 

1 was tubal pregnancy ; 
1 " obesity ; 
1 " mesenteric ; 
1 " splenic ; 
1 " not stated. 
So great did the difficulties of diagnosis for a long time prove that 
they were urged by the opponents of the operation as a valid objection 
to it as a surgical procedure. This, of coarse, is absurd. At the same 
time that these difficulties are still acknowledged, and that it is admitted 
that the most cautious and skilful diagnostician may be defeated by 
them, it can be confidently asserted that every year's experience 
greatly diminishes them, and that with the improved means now at 
command an experienced examiner will rarely be misled. Let us, 
however, again insist upon the fact that immunity from oft-repeated 
errors can be obtained, even by such an one, only by strict adherence 
to a conscientious and exhaustive examination of every case, a resort 
to all the known means of diagnosis, and a methodical exclusion of all 
conditions calculated to mislead. 

It is a fact which we daily see demonstrated that an inexperienced 
diagnostician usually arrives at a conclusion by the application of a 
much smaller number of tests than a veteran examiner would dare to 
do. The latter has been so often deceived that he knows his weakness ; 
the former has yet to learn. 

The means of physical exploration which are at our disposal are the 
following : 

Inspection and manipulation ; 

Mensuration ; 

Palpation ; 

Percussion ; 

Auscultation ; 

Vaginal touch ; 

Rectal touch ; 

The uterine sound ; 

Aspiration or paracentesis ; 

Chemical and microscopical examination of fluids of the tumor; 

Explorative incision. 
Solid ovarian tumors are rare, and seldom assume very large pro- 
portions, and, although ovariotomy is sometimes demanded for their 
removal, the operation is specially adapted to cystic tumors. We 
therefore pass to the more careful consideration of the diagnosis of 
these, and their differentiation from other abdominal enlargements. 

An ovarian cyst usually develops markedly on one side of the abdo- 
men, and if multilocular the abdominal distension is not symmetrical 
even in advanced periods. As it increases the cyst pushes the intes- 
tines aside into the hypochondriac regions. The ascending and trans- 
verse colon alone approximate their normal positions, and the omentum 
majus is usually pushed up over the front of the tumor. While the 
cyst is in the pelvis the uterus usually lies in front of it. but as 
increase of growth occurs it is ordinarily pushed behind it. There are. 
however, exceptions to both these statements. In rare cases, form- 



700 OVARIAN CYSTS. 

nately for the ovariotomist, a portion of intestine runs across the surface 
of the tumor, being fixed there by adhesion. The uterus, even late in 
the development of a large cyst, may be found in front of it, or latero- 
flexed, latero-verted, or even drawn completely above the pelvic brim. 
Curious as it may appear, great diversity of statement exists concern- 
ing the relation of cyst and uterus among writers on this subject. 
" Simpson's remark," says Peaslee, 1 "that 'if the sound show a tumor 
in front of the uterus the disease is certainly not ovarian,' is incorrect. 
The uterus is in front of an ovarian tumor only in exceptional cases, 
but is often so in cases of uterine fibroma and fibro-cyst." An ovarian 
cyst which has developed between the layers of the broad ligament 
usually grows downward, and is at first most prominently felt to one 
side of and behind the cervix, pushing down the vaginal vault. The 
uterus is always in front. This deep position in the pelvic cavity and 
immobility of a fluctuating cyst always point to an intraligamentous 
effusion, be it ovarian cyst, broad-ligament cyst, blood and serum (from 
ruptured tube perhaps), or pus. Our observation certainly agrees with 
that of Dr. Atlee, 2 that " the uterus may be dragged up or tilted up 
out of the pelvic cavity by the tumor, or, through these influences, it 
may be found on either side or displaced forward or backward within 
the pelvis. It may also be crowded downward against the perineum, 
or entirely extruded through the vulvar orifice. So that there is 
no general rule as regards the position of the uterus in ovarian 
tumors." 

When the tumor has ascended above the umbilicus, as the patient 
lies upon the back the abdomen will appear rotund, a decided pro- 
tuberance existing, and very little flattening out by sagging of fluid to 
the flanks occurring. As the hands are laid upon the surface and 
manipulation is practised, a firm, dense mass will be felt, which yields 
fluctuation, not usually of a superficial character like ascites, but less 
superficial and perceptible. Percussion will yield dulness all over the 
surface of the tumor and in one flank, but in the other resonance will 
generally exist. The surface of the tumor will often feel irregular and 
lobulated, and in multilocular tumors be more voluminous on one side 
than the other. If pressure be made upon the tumor as the patient lies 
upon the back, it will resist like a full sac, and not yield, and the pul- 
sations of the aorta may be felt obscurely through it. By vaginal and 
rectal touch the lower surface of the tumor may be felt and obscure 
fluctuation elicited. 

Mensuration practised from the umbilicus to the sternum, and the 
umbilicus to the anterior superior spinous processes of the ileum, will 
generally show a marked difference between the two sides in polycysts, 
and less difference in monocysts. In ascites the two sides are sym- 
metrical. Auscultation serves to exclude pregnancy. By vaginal 
touch the position of the uterus as well as its mobility is ascertained, 
and when combined with conjoined manipulation the solid or cystic 
character of a small or even a large tumor may be determined by it. 
Should the tumor be found low in the pelvis in the later periods of 
growth, it is probable that a short pedicle exists, and also probably 

1 Op. cit, p. 115. 2 Op. cit., p. 46. 



PHYSICAL SIGNS. 



701 



adhesions. Should it have risen out of the pelvis, the pedicle is prob- 
ably, but by no means certainly, a long one. 

The uterine sound informs us as to the capacity, the mobility, and 
the sensitiveness of the uterus, as well as, to a limited degree, its rela- 
tions to the tumor. 

A rectal examination with one or two fingers may aid in the dia- 
gnosis of ovarian tumors, but is usually necessary only in intraliga- 
mentous cysts. 

Emptying the cysts of the tumor of fluid by aspiration is likewise a 
most useful means of gaining information, and of great moment is the 
careful and intelligent examination of the fluids removed. 

Lastly, we reach the crucial test of explorative incision, the value 
of which cannot be exaggerated, and which is attended by little danger. 
In fact, whenever there is the least doubt as to the diagnosis the abdom- 
inal incision should at first be made small — say not longer than two 
inches — so as to admit the two first fingers of the left hand ; it can then 
always be enlarged if found necessary, or closed if removal of the tumor 
proves impracticable. 

These are the means by which the positive signs of ovarian cystoma 
may be elicited, but before a diagnosis is arrived at by deductions based 
upon them many other abdominal enlargements must be carefully con- 
sidered and excluded. If this be necessary merely in arriving at a cor- 
rect diagnosis where no operation is to be practised, how much more so 
is it in view of the grave procedure of ovariotomy ! Any one of the 
following conditions may mislead the investigator, and each of them 
must be in turn considered by him who desires to do his full duty to 
his patient and himself: 

Abnormal thickness or tension of n?i 

i j t n < Lbidema ; 

abdominal walls. J m • 

(^ Ionic spasm. 

Tympanites ; 
Fecal tumor; 
Dilatation of stomach ; * 
Distended bladder ; 
Hematometra ; 
Physometra ; 
Hydatiform mole ; 
Hydro-salpinx. 

Fluid accumulation within the peri- J ^ , \ -, 
toneum. V i Encysted dropsy ; 

(^ Hematocele. 
' Cyst of broad ligament ; 
Renal c} r st ; 
Splenic cyst : 
Hepatic cyst ; 
Parasitic cyst ; 

Omental and pancreatic cyst ; 
Uterine cysto-fibronia. 

is recorded bv Dr. Beeves 



Distension of abdominal viscera. 



Cystic disease of other parts in the 
abdomen. 



1 A most remarkable and interesting instance of this 
Jackson of Chicago. 



702 OVARIAN CYSTS. 

Uterine fibroma ; 

Enlarged spleen ; 

Enlarged liver ; 

Excessive development or displace- a fe ~ ,\ , , , 

n ,1 • f ,1 r i i i fearcoma oi abdominal glands ; 

ment of other viscera ol the abdo- < X t t *. j- 



men. 



Pregnancy. 



Malignant disease ; 
Omental tumor ; 
Displaced kidney ; 
^ Displaced liver. 
Normal ; 

( Ventral ; 
Extra-uterine < Tubal; 

(_ Interstitial 
With amniotic dropsy ; 
With ovarian cyst ; 
With dead child. 



Abnormal Thickness or Tension of Abdominal Walls. — Obesity 
will be recognized by obscure resonance on percussion over the whole 
abdomen ; by absence of a defined, resisting outline to the supposed 
tumor ; by the possibility of catching the fatty walls between the two 
hands, lifting them, and rolling them over the muscular floor beneath ; 
by the deep depression which can be made when the patient is anaes- 
thetized ; and by the pendulous folds created by assumption of the sit- 
ting posture. It would be inexcusable in an expert to mistake this 
condition for ovarian tumor, but for an inexperienced examiner not at 
all so. We see numerous cases every year in which such an error is 
committed by very competent practitioners. 

(Edema will be known by pitting upon pressure ; by the existence 
of the same condition in the areolar tissue of the feet or face ; and by 
its generally attending uraemia, chlorosis, or cardiac disease. 

Tonic spasm of the abdominal muscles has more than once led, as 
has indeed obesity, to abdominal section for removal of a tumor. It 
often occurs under the name of "phantom tumor" in very hysterical 
women, and is not rare as a reflex result of caries of the vertebrae. It 
may be diagnosticated by resonance on percussion, absence of fluctu- 
ation, and absence of all signs of tumor under anaesthesia. In case of 
doubt anaesthesia should always be resorted to. In addition to these 
signs the unaltered position of the uterus constitutes an important one. 

Distension of Abdominal Viscera. — Even without abdominal spasm 
a large amount of air sometimes accumulates in the intestines from hys- 
teria, digestive disorder, or great obstruction in the canal. It may be 
known by resonance on percussion, absence of fluctuation, absence of 
all signs of tumor upon examination under anaesthesia, and the normal 
position of the uterus. By firm, steady pressure downward toward the 
spine, kept up and increased after each expiration, resistance will be 
overcome, and deep exploration prove the absence of a tumor. 

Fecal tumor will be marked by absence of fluctuation ; a peculiar 
"doughy" sensation upon manipulation; pain upon pressure; consti- 
pation ; violent colic ; and, most valuable sign of all, the creation of a 
distinct pit or depression when steady pressure is made at one point, the 



ADHESIONS. 



703 



patient being anesthetized. The action of cathartics and enemata is 
often entirely delusive as a test of fecal tumor. 

The possibility of mistaking a distended bladder, accumulations of 
blood, fluid, and air in the uterus, and of fluid in the Fallopian tube, 
for an ovarian cyst, has already been pointed out under " Differentia- 
tion." The same applies to encysted peritoneal effusions and general 
ascites. We will therefore refer the reader to that section. 

Fibro-cystic tumors are difficult of differentiation from ovarian cysto- 
mata, but when we compare our present position with reference to this 
subject with what it was only a few years ago, we have great cause for 
congratulation. We here give only the most prominent differences 
between the two diseases, and hence those upon which reliance can 
really be placed. To many of these even, however, there are excep- 
tions ; to several there are none : 



Uterine Fibro-cyst — 

Grows slowly, and occurs usually after 
thirty years of age. 

Uterine cavity generally enlarged. 

Connection of" tumor and uterus usually, 
though not always, intimate. 

Fluid spontaneously and quickly coagu- 
lates. 

Uterus sometimes lifted above pubes and 
out of pelvis, often in front of tumor. 

Health remains good for years. 

Microscope shows fibre-cell (Drysdale). 



Ovarian Cyst — 

Grows more rapidly and is less governed 

by age. 
Uterine cavity not usually enlarged. 
Uterus more independent of tumor. 

Never does so. 

Uterus generally behind tumor. 

Generally fails within three years. 
Shows the peculiar granular and epithe- 
lial cells of ovarian cyst. 

Although these signs are all of some value, those which should be 
regarded as most reliable are the following : spontaneous coagulability 
of contained fluid ; presence of the fibre-cells ; increased capacity of 
the uterus ; and the determination of its connection with the tumor by 
means of rectal exploration. Explorative incision should not rank high 
as a diagnostic method, for simple section of the abdominal walls is not 
enough, and the exploration which is further required to decide the 
point exposes the patient to great danger. 1 

Diseased State of Pelvic Walls and Areolar Tissue. — Enchondroma 
or ejicephaloid disease of the pelvic walls is hard, free from fluctuation, 
and firmly fixed and united to the part from which it grows. Rectal 
exploration and abdominal palpation will prove these facts, and if 
aspiration be attempted the absence of fluid will be evidenced. 

Pelvic abscess usually results from cellulitis, which presents marked 
symptoms. It rarely extends to the umbilicus, hardness will be felt in 
one or other iliac fossa, it is fixed in the pelvis, and aspiration gives 
evidence of pus. Excessive pain attends it, with throbbing and pain 
down one thigh, and the outline of the mass is obscure and unsatis- 
factory. There is often a tendency to point, there is pain upon pressure. 
and there are generally chills and fever. 

Adhesions. — In the early days of ovariotomy, when adhesions were 
regarded as a bar to extirpation of these tumors, the question of the 
existence of adhesions possessed important bearings. Now. however, 

1 AVe retain this tabic of signs because we doshe to emphasize the difficulty of dia- 
gnosing a uterine tibro-evst. 



704 OVARIAN CYSTS. 

when even the firmest attachments are broken or tied and divided 
with impunity, it sinks into comparative insignificance. This is a most 
fortunate fact, for the reason that the determination of the existence 
of adhesions is little more than guesswork. Beyond a few very general 
facts, by which we may venture to form a surmise, all is empirical pre- 
diction with reference to the matter. 

If the case have developed very rapidly and be believed to be uni- 
locular, there are probably no adhesions. 

If there have been symptoms of peritonitis, there are probably adhe- 
sions. If the case have been painless, there are probably none. 

Should the abdominal walls roll freely over the tumor, the patient 
lying upon her back, and should the tumor fall low in the abdomen as 
she suddenly sits up, there are probably no anterior adhesions. But 
omental, intestinal, and posterior ones may exist, and not be suspected 
from this examination. 

If upon vaginal examination the uterus and base of the tumor 
exhibit immobility, such as is found in pelvic peritonitis, and if, upon 
change of posture from erect to supine, these parts do not retreat from 
the finger in the vagina, there are in all probability strong pelvic 
adhesions. 

All these signs are unreliable, and disappointment will surely follow 
any great degree of confidence which is reposed in them, but a compen- 
sation is to be found in the fact already stated that even firm adhesions 
do not contraindicate removal. 

The Pedicle. — The length of the pedicle is of no special importance, 
so far as ease of transfixing, ligation, or recovery is concerned. Small, 
high, and very movable tumors usually have long and thin pedicles. 
The thinner and longer the pedicle and the more movable the tumor, 
the more likely is torsion to occur. Of course a thin, slender pedicle 
is preferable to a thick, fleshy one, which latter requires much more 
force to ligate firmly ; and a healthy pedicle is superior to one diseased 
by torsion or peritonitic exudation, and therefore liable to be cut by 
the ligation and to bleed. But otherwise it is of no value to endeavor 
to ascertain the length and size of the pedicle before operation; and 
indeed this can seldom be done. 

When doubts exist upon any of the points here stated, which cannot 
be removed by those means of investigation which are limited by the 
abdominal walls and pelvic roof — which, in other words, extend to, but 
not beyond, the peritoneum in their immediate application- — there exist 
three methods of exploration which bring the explorer into direct con- 
tact with the interior of the abdomen and of the tumor. These positive 
and reliable means, which may justly be styled the crucial tests of 
abdominal tumors, are the following : 
Aspiration ; 
Tapping ; 
Explorative incision. 

To these a certain amount of danger undoubtedly attaches, but when 
compared with the great danger arising from operation upon an uncer- 
tain diagnosis it becomes trivial. Many an inappropriate case has been 
submitted to the operation of ovariotomy which would have been spared 



ASPIRATION. 705 

it, with the promise of a prolongation of life, had one of these methods 
been previously employed. They are, of course, not to be confined to 
the determination of the character of a tumor alone, but that of the 
origin, attachments, and complications of any abdominal growth. 

Aspiration. — The introduction of aspiration into use for the diag- 
nosis of ovarian tumors constitutes a decided advance. The instrument 
generally employed in this country is that of Potain, shown in Fig. 
28. By this a delicate, hollow needle is passed into the tumor, and 
powerful suction applied through an India-rubber tube connected with 
a strong syringe, in which a vacuum is created by an upward movement 
of the piston. Through the most delicate needle clear fluids will pass, 
and through the largest, which is very small when compared with an 
ordinary trocar and canula, very tenacious colloid material may be 
drawn. With the aspirator a supply of fluid for chemical and micro- 
scopical examination may be withdrawn. The danger of aspiration is 
much smaller than that of tapping, which latter may cause : 1st, hem- 
orrhage from a blood-vessel in the abdominal or cyst-wall ; 2d, admis- 
sion of air to the cavity of the sac and decomposition of fluid, which 
may create inflammation of the cyst- Avail and septicaemia ; 3d, subse- 
quent escape of the contents of the tumor into the peritoneum ; and 
4th, fatal injury from wounding of an intestine or solid organ. Spen- 
cer Wells mentions a case in which an acquaintance of his tapped a 
patient who died soon after. Upon autopsy two and a half quarts of 
blood, which had escaped from a wounded varicose vein, were found in 
the peritoneal cavity. A similar accident per vaginam occurred to Dr. 
A. Reeves Jackson of Chicago. All these dangers are considerable 
from ordinary tapping ; decidedly less so from aspiration. 

It may, then, safely be said that aspiration accomplishes all that 
tapping does, at infinitely less risk, and that the former should, when 
practicable, always be preferred to the latter procedure. When it is 
desired merely to obtain a small amount of fluid for examination, the 
hypodermic syringe may be employed, even in preference to the aspi- 
rator. [The use of this instrument, which was suggested by Dr. H. F. 
Walker and practised by myself before our knowledge of that just 
described, consists simply in plunging the needle with syringe attached 
through the abdominal walls at different points, drawing out as much 
fluid as possible, and expelling this into a test-tube for examination. — 
T. G. T.] This method serves to determine the following points : 1st, 
whether a tumor is fluid or solid ; 2d, whether it contains clear, slightly 
albuminous fluid or ichorous and irritating material ; 3d, by means of 
several punctures whether it be multilocular or not. 

Although it has been stated that aspiration is much less dangerous 
than tapping, it must not be regarded as free from danger. Death lias 
repeatedly resulted from it, and it should be regarded as an axiom that 
all abstraction of fluid from an ovarian cyst, by whatever means it is 
accomplished, is attended by danger. The smaller the puncture made, 
however, the less the danger, I think. Cases of peritonitis, some of 
them fatal, after aspiration, are recorded by Atlee, Little, Lusk, Mamie, 
Gillette, and Jenks ; cases of decomposition of sac-contents and septic 
fever are reported from the same cause by Goodell, Peruzzi, Schnetter, 



706 OVARIAN CYSTS. 

Skene, and Thomas ; and a case of peritonitis and adhesions after dia- 
gnostic puncture by a hypodermic needle by Fauntleroy of Virginia. 

Tapping. — Tapping, although resorted to in previous years, indeed 
almost since time immemorial, has now been entirely discarded in the 
diagnosis and treatment of ovarian tumors, for the reason that it is not 
only unnecessary (the aspirator answering every purpose), but unsafe, 
and, according to Tait, productive of adhesions which greatly lessen 
the chances of recovery from a subsequent ovariotomy. According 
to Kiwisch, of 130 cases of tapping, 17 per cent, died within a few 
hours or days after the operation. As this mortality by far exceeds 
that from ovariotomy at the present day, tapping has naturally fallen 
into disuse. 

The circumstances which ordinarily indicate the propriety of 
paracentesis as a palliative measure when immediate removal of the 
tumor is for some reason or other impracticable, are — rapid accumu- 
lation, which interferes with some important function ; coexistence of 
ovarian disease with pregnancy ; solitary character of the cyst ; firm 
adhesions which bind the tumor down so as to prohibit a more rad- 
ical procedure ; great doubt as to diagnosis ; or constitutional debility, 
which prevents the tolerance of a more serious operation. The ope- 
ration may be performed through the abdominal, vaginal, or rectal 
wall, nearly always the first named. 

Tapping through the Abdominal Wall. — This is done by a trocar, 
the skin being first incised under antiseptic precautions. The median 
line midway between umbilicus and pubes is the point preferred. The 
patient should be in the recumbent position, and the abdomen be well 
bound after evacuation of the fluid. The only instances in recent 
years in which we have resorted to tapping of the abdominal cavity 
have been not of ovarian cysts, but of ascites, which obscured the 
diagnosis of a pelvic or abdominal tumor. 

Tapping through the Wall of the Vagina. — This procedure is limited 
now almost entirely to intraligamentous ovarian cysts, cysts of the broad 
ligament, or effusions of blood between the layers of the broad ligament 
(pelvic hematoma). It is followed by dilatation of the puncture with 
the divergent dilator and irrigation of the sac, which is either packed 
with iodoform gauze or drained through a large rubber tube. For 
description of this method we refer the reader to the section on Pelvic 
Hematoma. 

Explorative Incision. — Of all the means for definite and certain set- 
tlement of the question of diagnosis in abdominal tumors, we esteem 
explorative incision most highly. As, however, it involves not only 
opening the peritoneal cavity, but usually considerable manipulation 
of its contents, it necessarily involves a certain amount of danger. 
While the other methods may be practised several days or even weeks 
before the operation of ovariotomy, this should constitute, or rather be 
merged into, its first step. If it yields information which makes the 
surgeon decide against operation, the opening made should be closed ; 
if the light which it throws upon diagnosis favors the radical procedure, 
the incision should be at once enlarged and prolonged into the final 
abdominal opening. 



TREATMENT. 707 

Explorative incision should be thus performed : The patient having 
been prepared for the procedure exactly as if we had determined upon 
ovariotomy, she is placed upon the table and surrounded by assistants, 
etc., as in the case of the radical operation. An incision is then made 
by the bistoury upon the median line, one inch in length. This is car- 
ried down to the tumor, and the finger is at once gently swept over this 
in every direction, so as to ascertain its character. The tumor may be 
emptied with a very small trocar — so small that the opening made may 
be readily closed if it be deemed best to desist from radical operation — 
or by the aspirator. If the sac be emptied by this means, the hand is 
then passed into the abdominal cavity and complete exploration made. 
If it be not completely emptied, a sound should be passed into the uterus* 
and two fingers or the hand carried down through the abdominal open- 
ing to the fundus uteri, to ascertain as accurately as possible the origin 
and attachments of the solid mass. In case abdominal effusion have 
existed, this of course at once flows away, and any growth existing in 
the abdomen comes within the reach of the finger. 

Before leaving this part of our subject let us lay before the reader 
a few rules, the observance of which will diminish very greatly the 
chances of his falling into errors of diagnosis in operating for ovarian 
tumors : 

1st. Never perform ovariotomy without carefully exploring the uterus 
by the sound, if this be possible. 

2d. Before operation, should doubt exist as to diagnosis, always 
remove a small amount of fluid by the hypodermic syringe or aspirator 
for chemical and microscopical examination. 

3d. If any doubt whatever exist as to diagnosis, anaesthetize the 
patient and examine carefully. 

4th. Should all doubts not be cleared up at the moment of opera- 
tion, begin it as an explorative incision, and proceed or not as instructed 
by what is discovered. 

Treatment. — The medical treatment of ovarian dropsy by diuretics, 
hydragogue cathartics, diaphoretics, mercurials, absorbents, mineral 
waters, etc. has now been faithfully tested and found to be inefficacious. 
After a careful search through the records of the subject, one is forced 
to the conclusion that there is a lack of evidence substantiating the 
possibility of the accomplishment of absorption by these means. All 
that can be anticipated in these cases from medication is sustaining the 
nervous and sanguineous systems by tonics and stimulants ; regulating 
disordered functions by diaphoretics, cathartics, diuretics, and anti- 
emetics; and relieving local inflammations by the ordinary means 
usually resorted to under such circumstances. We are the more urgent 
in insisting upon the fact of the inefficacy of constitutional treatment 
because we formerly met with many fully-developed eases of ovarian 
cyst which bore evidence of a variety of attempts by cupping, leech- 
ing, inunction, painting with iodine, and correspondingly active internal 
treatment to dissipate the accumulation. To the attempts to obliterate 
ovarian cysts by the injection of tincture of iodine (a great advocate 
of which twenty-five years ago was Boinet) we need but refer as a matter 
of history. The same applies to Semeleder's project to cure these cysts 



708 OVARIOTOMY. 

by electrolytic puncture, a proposal made as late as 1876, and, we 
believe, still upheld by its author. Munde 1 showed the danger and 
futility of this practice, which at present has no supporters whatever, 
even among the most enthusiastic electro-therapeutists. Very small 
cysts may occasionally be absorbed or cured by local alterative and 
counter-irritant treatment. Winckel 2 mentions one case of a tumor 
of the size of an apple which was reduced by the steady use of brine 
baths (Kreuznach, Hall, or Tolz) to about normal size. Monocysts not 
larger than an egg have several times been ruptured accidentally, and 
intentionally by bimanual pressure by Noeggerath and Munde 3 without 
evil results. 

But the fact nevertheless remains that there is only one sure cure for 
an ovarian tumor, and that is its removal. It is entirely unnecessary 
at the present day to discuss or defend this question, which is definitely 
settled for all time. 



CHAPTER XLIV. 

OVARIOTOMY. 

Definition. — Ovariotomy consists in the extirpation of the diseased 
ovaries. At the present day this term is used only to designate the 
removal of an ovarian tumor. The extirpation of ovaries not so dis- 
eased as to be worthy of the name of u tumor " is called "oopho- 
rectomy." 

History. — The history of ovariotomy goes back only to a very re- 
cent date. It has become customary for those who have written upon 
it to cite ancient authors to prove that even as long ago as the time of 
the early Greeks the ovaries were often removed in the inferior animals, 
as is done in our own time. The writings of Aristotle put this beyond 
question. It is even asserted that among the Lydians castration of the 
human female was practised in order to enable them to serve as eunuchs. 
In more recent periods we are told by Wierus that a Hungarian swine- 
herd, incensed by the lasciviousness of his daughter, removed her ovaries 
in hope of reformation, after the manner in which he was in the habit 
of spaying his swine. Toward the close of the eighteenth century both 
ovaries, which had descended into the inguinal canals, were removed by 
Dr. Percival Pott of England. But all this, though interesting as a 
matter of history, has little to do with the operation of ovariotomy, 
according to the true signification of the term. In the one case a 
minute and healthy gland, which is sparsely supplied with blood, was 
removed from a healthy peritoneal cavity. In the other a huge sac, 
which is supplied by large blood-vessels and has in many instances con- 
tracted adhesions to a diseased peritoneum, requires extirpation. 

1 Munde, Amer. Gyn. Trans., 1877. ' 2 Loc. cit., p. 557. 

3 "trans. N. Y. Obst. Soc," Am. Journ. Obst, 1876. 



HISTORY. 709 

The idea of removing large ovarian cysts, even, is not new, since it 
was discussed in 1685 by Schorkopff, in 1722 by Schlenker, in 1731 by 
Willius, in 1751 by Peyer, and in 1752 by Targioni. In 1758, Dela- 
porte even went so far as formally to propose the operation to the Royal 
Academy of Surgery. As the eighteenth century approached its close 
the suggestions of the writers already mentioned were not forgotten, but 
were from time to time repeated, among others by John Hunter in 1787, 
and later still by William Hunter. In 1798, Chambon ventured to 
prophesy that it would in time become a recognized resource in sur- 
gery ; and in 1808, 1 Samuel d'Escher, a student of Montpellier, pro- 
posed a specific plan for its performance based upon the teachings of 
one of his masters, M. Thumin. 

In 1786 one observer stood upon the very verge of the great dis- 
covery, very much nearer than Laumonier, by some supposed to be the 
discoverer, ever did, and yet failed to systematize it as a surgical 
resource. Like many a man before and since his time, he recognized 
and appreciated a fact, but failed to connect this with a law. The fol- 
lowing is a quotation from a work written by Thomas Kirkland, an 
Englishman, and published in London in 1786. It is entitled An 
Inquiry into the Present State of Medical Surgery : 2 

" A woman, betwixt twenty and thirty years of age, had been tapped 
twice for an ascites, and a large quantity of water taken away at each 
time ; but after the last operation the puncture did not heal, and in a little 
time, a substance they did not understand protruding, I was desired to see 
her. It was evidently a part of a cyst, and, as it had already dilated the 
sore, I persuaded her to let it alone till the opening became larger, in hope 
of a better opportunity of affording relief. Accordingly, in ten days or a 
fortnight the protrusion was much larger, and by the help of a dry cloth a 
cyst that would contain five or six gallons of water was gradually ex- 
tracted. More than a quart of matter immediately followed, and more was 
daily discharged for some time, yet the woman recovered without further 
trouble, than keeping the parts clean, and afterward bore several children." 

Later on in his work he says : 

" We have given an instance (p. 195) where a cyst being taken away 
cured an ascites ; and, seeing medicines do not avail in encysted dropsies 
of the abdomen, is it not worth our while to consider whether, when they 
are unconnected with the adjacent parts, after taking away the water, the 
patient might not sometimes be cured by enlarging the puncture, pressing 
the cyst forward, and drawing it out?" 

He then proceeds to examine the difficulties in the way and the 
objections which may be brought against the operation, and thus con- 
cludes : 

" At present I offer these hints to those who think the subject deserving 
attention, and time will probably determine the question." 

Thus, as w r e advance from move remote periods to the beginning of 
the nineteenth century, we find the minds of physicians being gradually 

1 Wielahd and Dubrisay. French translation of Churchill on Dis. of Women. 

2 Med. Record, June 15, 1867, from exchange. 



710 OVARIOTOMY. 

prepared for the reception of ovariotomy as its consummation was step 
by step approached. But all that we find accomplished up to this time 
is the promulgation of ideas, prophecies, and propositions, and the per- 
formance of accidental operations or of those upon healthy ovaries. 

In 1809 the first real case of ovariotomy ever undertaken was suc- 
cessfully performed by Dr. Ephraim McDowell of Kentucky. His first 
case was successful, the patient living twenty-five years afterward. Sub- 
sequently he operated 13 times, with 8 favorable results. It may con- 
fidently be asserted that the history of no operation has been more 
thoroughly sifted than this, and that up to the present time nothing 
can be clearer than the fact that to McDowell belongs the credit of 
priority of performance. It is interesting to examine the competitive 
claims which have been put forward in reference to the matter. First 
in chronological order is that of Dr. Houstoun 1 of Scotland, who 
operated in 1701, and whose case, says Mr. Wells, 2 makes it "appear 
that ovariotomy originated with British surgery on British ground." 
This statement will excite wonder, and the claims of the operator fail to 
attract attention when it is stated that nowhere does Houstoun claim to 
have removed the cyst or even a part of it. He merely treated a case 
of ovarian cyst successfully by incision. 

The second is that of Laumonier of France. Of him Baker Brown 
says : " The first who attempted extirpation appears to have been 
Aumonier of Rouen in 1782, and he was successful." In this state- 
ment, as Dr. Parvin has pointed out, Mr. Brown was wrong in three 
points : first, as to the fact ; second, as to the name of the operator ; 
and third, as to the date. The supposed ovariotomy was performed in 
1776 by Laumonier, and was really the opening of a pelvic abscess. 

The third is that of Dzondi of Halle. As the patient was a boy, 
the claim requires no further consideration. 

In 1821, Dr. Nathan Smith of this country operated successfully. 
He was from New Haven, Conn., but was lecturing at Dartmouth 
Medical College. His operation was performed in Norwich, Vermont, 
the ligatures used being strips cut from the buckskin gloves of the 
operator. The pedicle was dropped. In 1823, Dr. Lizars endeavored 
to introduce the operation into Scotland, and operated four times, but 
his results were bad. In one case the tumor was uterine and was not 
removed ; in one no tumor could be discovered after abdominal section ; 
and one of the two cases upon Avhich ovariotomy was performed died. 

Since this period, Atlee, Peaslee, Kimball, and Dunlap were most 
influential in establishing the operation in America. In England, Dr. 
Charles Clay in 1840 pressed it upon the notice of the profession, and 
he was soon ably sustained by Lane, Wells, Keith, Bryant, Baker 
Brown, and many others whose names have become famous in connec- 
tion with it. 

" It is only within the last five years," says Grenser, writing in 
1871, " that much progress has been made in Germany in this opera- 
tion." Unfortunately, for many years insuccess appeared to attend it, 
and thus the voices of the most eminent and authoritative were raised 
against it. Of the first 3 patients ever operated upon there (by 

1 Amer. Journ. of Med. Sciences, vol. ii., 1849, p. 534. 2 Op. cil, p. 299. 



HISTORY. 711 

Chrysmar in Wurtemberg), 2 died. Chrysmar commenced operating in 
1819, and his results were certainly not such as to popularize a new 
and dangerous procedure. In 1828 the adverse criticism of the great 
Dieffenbach was pronounced in these strong terms : '- Whoever 1 con- 
siders the opening of the abdominal cavity as a light matter, and, as 
Lizars seems to believe, that the difficulties are small ; whoever thinks 
that this operation is accompanied by no more dangers than other 
operations, must be very thoughtless ; for me, my one case is sufficient." 
The " one case " to which he refers, and from which he drew so illogical 
and hasty a conclusion, was an incomplete operation. In spite of the 
adverse weight of this opinion, in 1835 Quittenbaum, in 1841 Stilling, 
and in 1851 Martin, operated on a few cases and with varying success. 
Writing of the operation at this time, when, overclouded by repeated 
insuccesses, it had failed to command the confidence of the profession, 
Grenser says : " Most of the ovariotomies performed within the last 
forty years had a fatal termination, and as a consequence reliance could 
not be felt in it, and confidence in it was altogether shattered when the 
celebrated Dieffenbach took ground against the operation." Dieffen- 
bach's opinion in 1828 has been given ; let us see how the experience 
of twenty years affected it. In 1848 he wrote : "The operation does 
not benefit either patient or physician ; the idea of opening into the 
abdomen of a sick, cachectic woman, affected with a hard tumor of 
the ovary, or even employing Lizars' method with cross-incisions, in 
order to remove the tumor by force, seems neither reasonable nor use- 
ful." He modified his opinion somewhat where the tumor was fluid, of 
small size, and movable. Thus wrote the great surgical light of Ger- 
many, and while he wrote American and English surgeons were gaining 
great results for humanity and for science in this same field. It must 
not be supposed that even in his own country advances were not being 
made, for Stilling, Biiring, and others were carrying on the work. In 
1850 the latter announced an important advance — namely, that adhe- 
sions should not be considered as a contraindication to removal. 

In 1852, Edward Martin declared that the question was no longer 
as to the propriety and efficiency of ovariotomy, but of circumstances 
favorable to success. Martin's rules for operating, read even by our 
present lights, are most of them excellent. 

About this time the voice of Kiwisch was raised against the ope- 
ration. He 2 collected the statistics of 54 cases, of which 51 ended 
fatally, and concluded that certainly over half of all submitted to 
operation died. It was soon after this that Scanzoni and Gustav 
Simon gave their evidence against the operation, and increased its 
disfavor to such a degree that, as Grenser says, " its very existence 
was threatened." This opposition seems to have lasted up to 1864, 
when the tide appeared to turn in its favor, and it soon numbered 
among its advocates Breslau, Gusserow, Hildebrandt, Spiegelberg, 
Martin, Stilling, A r eit, Wagner, and Billroth. Grenser collected in 
1871 the statistics of 129 operations performed in Germany, of which 
60, a little less than half, recovered. When these results are compared 
with English and American statistics of that period, they show that 

1 Grenser, Report on Ovariotomy in Germany. - Grenser, toe, cit. 



712 OVARIOTOMY. 

Germany had much to make up. That she has done this is proved by 
the excellent results obtained by Schroeder, Olshausen, Martin, Leo- 
pold, Gusserow, Fritsch, Winckel, Chrobak, Peter Muller, Hegar, Sanger, 
and others too numerous to mention ; and to-day it must be conceded 
that in Germany the operation of laparotomy, whether for ovarian 
tumors or other abdominal diseases, has attained a perfection second to 
no other country. 

According to Grenser, we owe to Germany two of the most im- 
portant of the improvements which have taken place in the operation 
since the days of McDowell : first, the adoption of the short incision 
and tapping the sac in situ", which originated with Quittenbaum ; sec- 
ond, the external treatment of the pedicle, which he declares was first 
resorted to and its advantages insisted upon by Stilling in 1841, and 
not by Duffin in 1850. In 1849, Martin first secured the pedicle in 
the lips of the wound. There are other advances which have been 
made in Germany, but we mention only those which have had a decided 
influence on the operation. 

Into France the operation was introduced, or, as some French l 
writers express it, " reintroduced," by Dr. Woyerkowski in 1844. It 
was subsequently performed by Vaullegeard in 1847, and later still by 
Nelaton, Maisonneuve, Jobert, Demarquay, and other surgeons of 
Paris. The results of these attempts, however, had the effect of cast- 
ing discredit on the operation, from which it is only now emerging, 
thanks to the writings of Jules Worms, Oilier, Labalbary, Vegas, and 
more especially to those of Koeberle' of Strasbourg. When it is stated 
that all these writers have published since 1862, it will be appreciated 
how recent is the favorable reception of the operation in France. 

M. Boinet in 1867 read an essay before the Academy of Medicine : 
strongly advocating it, and "reprobating the timidity of French sur- 
geons who have so I0112; recoiled before it." 

Up to July, 1868, Pe'an of Paris had had 7 recoveries out of 10 
cases, and in 1870 and 1871, out of 32 operations 26 recoveries took 
place. In 1873 he wrote a work upon Hysterotomy for Fibroids and 
Fibro-cysts, in which he claims 7 recoveries for 9 operations. Nothing 
could more surely mark the advance of the operation, as well as the 
rapidly increasing boldness and skill of French surgeons, than this 
announcement. 

It is needless to point out the fact that to-day all opposition to the 
operation has disappeared, and that in every civilized country of the 
globe it stands among the proudest achievements of surgery. 

In concluding the history of ovariotomy it may be said that the con- 
ception of the operation in all its steps is over a hundred years old, and is 
of European origin ; that for its accomplishment we are indebted to what 
M. Piorry once styled " une audace Ame'ricaine, " which was supplied 
by Ephraim McDowell; and that many of the important improvements 
which have since been introduced we owe to Great Britain. Pre- 
eminently an Anglo-American procedure, it has only within the last 
twenty years assumed its legitimate place in Germany and France. 
But the former country has since then distanced all competitors by the 

1 Wieland and Dubrisay, the French translators of Churchill. 



VA BIETIES-STA TISTICS. 713 

enormous strides which ovariotomy and abdominal section for other 
indications have made. No case seems too hazardous for the German 
laparotomist, and his successes, it must be admitted, justify his boldness. 
France has lately been coming rapidly to the front under the guidance 
of the younger generation. In our own land ovariotomy is so fre- 
quently practised as to be no longer a subject for comment, and Amer- 
ican laparotomists need not fear comparison with the best of other 
countries. 1 

Varieties. — There are two forms of the operation : one, abdominal 
ovariotomy, in w r hich the cyst is removed through the incised abdominal 
walls ; the other, vaginal ovariotomy, in which a small cyst is removed 
by incision through the fornix vaginae. Incomplete cases, or those in 
which only a portion of the sac is removed, have also been grouped 
under the first head, since in its essential details the steps of the ope- 
ration are the same up to the point when the possibility of the entire 
removal of the tumor is decided or it becomes apparent that a portion 
of it will have to be sewed into the wound. 

Dangers. — The removal of an ovarian tumor differs in one great 
particular from many other operations, chiefly of the plastic variety. 
In these the operation may be a success or it may fail, but in either 
case the patient may recover, and be but little the worse for the risk 
and inconvenience he or she has experienced. But in an ovariotomy 
the case is different : here success means recovery. It is true the 
tumor may be successfully removed, and still the patient die. But 
that could hardly be called an operation with a successful result. On the 
other hand, failure to remove the entire cyst may still be a success, since 
the remnant left behind may shrink and close by granulation, and the 
patient eventually make a perfect recovery. Our own observations 
would lead us to put the causes of fatal issue after ovariotomy in the 
following order as to frequency and importance : 

Septicaemia ; 

Peritonitis ; 

Hemorrhage ; 

Shock. 
The first of these is the great evil to be feared, and, combined with 
the second, causes more deaths than all the causes added together and 
multiplied by ten. 

Statistics. — So hard was the struggle of ovariotomy for existence, 
so vigorous and malign the attacks made against it by the leaders of 
professional opinion all over the world, and so delicate the position of 
those bold and enterprising men who in the United States and England 
still clung to its fortunes, that up to a very recent period it was neces- 
sary to deal fully with statistical evidence endorsing it. That time lias 
now happily long since passed, ovariotomy now standing upon a basis 

1 [T remember distinctly how in 1867, when 1 was assistant to Prof. Sean/oni at the 
Maternity Hospital in Wtirzburg, the instruments for ovariotomy were procured from 
Prof. Koeberle at Strasbourg (who was the pioneer of the operation on the Continent), 
and how elated all concerned were when the patient recovered. It was a simple case, 
and nowadays would attract no attention or merit report. Then it was a great achieve- 
ment, which warranted its publication. One more successful case followed, and then 
a death, which promptly cooled the ardor of Sean/.oni. — P. F. M.] 



714 OVARIOTOMY. 

every whit as firm as that of amputation of the leg or any other long- 
accepted operation of general surgery. Then, too, since the universal 
introduction of antiseptic precautions results have been achieved which 
are simply marvellous, and which only so short a time as ten years ago 
would have been thought impossible. As in the major operations, the 
greater the skill of the operator the better usually his results. Skill is 
attained only by experience. Hence successive series of ovariotomies, 
published by the same operators, generally show a decreasing number of 
deaths, and those surgeons who have done many such operations as a rule 
have a greater number of recoveries to show than operators whose total 
of operations is small. At present the average mortality among 100 
unselected ovariotomies might fairly be put at about 10 per cent. This 
figure may vary three to five points either way in proportion to the acci- 
dental greater or lesser frequency of unusually difficult cases. Dohrn, 1 
of 100 ovariotomies performed between 1883 and 1889, lost but 4. Tait 
in his first series of laparotomies (which, by the way, does not mean ova- 
riotomies only, but removals of diseased tubes, ovaries, etc.) reports a 
mortality of 9.2 per cent., and in a second similar series of 5.5 per 
cent. C. Braun 2 in a second series of 100 cases had 93.5 per cent, 
of recoveries. Bantock 3 in his fourth 100 cases lost but 4 (employ- 
ing merely aseptic precautions), whereas in his first 100 cases, where he 
followed the Listerian practice of drenching the patient and all her 
surroundings in a weak solution of carbolic acid, he lost 19. 
The following table is copied from Olshausen (Joe. cit.) : 

Spencer Wells, 1000 cases, with 768 recoveries. 

Keith, 281 " " 340 

Koeberle, 306 " " 340 

Thornton, 423 " " 383 

Tait, 405 " " 372 

Olshausen, 293 " " 266 " 

Schroeder, 658 " " 575 

Hofmeier has arranged the cases of Schroeder according to each 
hundred, in order to compute the different rates of mortality with the 
increasing experience of the operator : 

From 1-100 17 deaths. 

" 100-200 ....:, 18 " 

" 200-300 7 " 

" 300-400 16 " 

" 400-500 7 " 

" 500-600 . 7 " 

" 600-658 11 " 

From 658 .83 deaths, or 12.5 per cent. 

In explanation of the large mortality of Schroeder's last 58 cases it 
should be stated that there was an unusual number of malignant 
tumors. 

The operation is thus shown to be a comparatively safe one — cer- 
tainly one not to be feared either by patient or operator, in view of the 

1 Dohrn, " Ein Hundert Ovariotomieen aus der Koenigsberger Frauenklinik," Cen- 
tralbl. f. Gyn., No. 9, 1890. 

2 Wiener Id. Wochenschr., 1888. 3 Brit. Gyn. Journ., 1889. 



CONDITIONS FAVORABLE TO THE OPERATION. 715 

almost certain fatal result which non-interference with the tumor will 
bring in the course of a few years. 

Conditions Favorable to the Operation : 

Clearness and certainty of diagnosis ; 

Good constitutional condition ; 

Patient hopeful and desirous for operation ; 

Paucilocular character of cyst ; 

Absence of much solid matter in its structure ; 

Abdominal walls not very thick ; 

Absence of strong pelvic adhesions. 
The possibility of error in diagnosis has been already sufficiently 
dwelt upon. The importance of clearly understanding the nature of 
the tumor cannot be over-estimated. The operator should, by repeated 
and most careful examinations, alone or with counsel, endeavor to deter- 
mine all the features of the case — not merely the fact that a tumor exists, 
but that it is ovarian and not uterine, that pregnancy does not exist 
with it, that it is not cancerous, that its contents are fluid, and that the 
fluid felt is all ovarian and none of it abdominal. [In two cases I have, 
in company with a number of others who consulted with me, been 
greatly deceived. In one case, when upon the point of operating upon 
a large, multilocular tumor, the patient lying on the table, I discovered 
the coexistence of pregnancy in the fifth month. In another, which I 
supposed to be a large ovarian tumor, upon cutting through the abdom- 
inal walls an immense amount of fluid escaped, leaving for removal a 
solid tumor of the ovary not larger than the adult head. — T. G. T.] 
Cases are on record in which surgeons of great experience and skill 
have cut down upon uterine fibroids, cysts of the kidneys, the pregnant 
uterus, and other abdominal enlargements under the impression that 
ovarian cysts existed, and instances have occurred in which abdominal 
section discovered no tumor of any kind, the operator having been 
deceived by tympanites. 

As to the period at which the operation should be undertaken, there 
formerly was a great deal of diversity of opinion. Thus, Baker Brown 
operated quite early, as soon as the diagnosis was fully established, in 
order to avoid changes in the cyst and peritoneum. Peaslee, Tyler 
Smith, and Keith waited for some degree of impairment of health and 
emaciation, as the object in waiting was to toughen the peritoneum 
against inflammation. But this precaution is now admitted to be entirely 
unnecessary. Wells operated when the patient could not walk a mile 
without difficulty. 

The practice generally in vogue at the present day, with which we 
substantially agree, is that any ovarian cyst which has attained a size 
meriting the dignity of that title (to fix an arbitrary limit) should 
be removed by abdominal section as soon as discovered. This rule 
may seem too positive and absolute to many conservative surgeons, and 
indeed ten or fifteen years ago it would probably have been an unwar- 
rantable interference with a condition which as yet was not giving rise 
to any particular trouble, and possibly might never do so ; but our 
vastly increased experience at the present day justifies us in advising 
the early removal of ovarian cysts, in view of the comparative safety 



716 OVARIOTOMY. 

of the operation, and chiefly in view of the accidents to which every 
ovarian tumor is exposed — namely, the twisting of the pedicle, the 
inflammation and suppuration of the cyst, and the formation of adhe- 
sions which may render its removal exceedingly difficult or even entirely 
impossible. Particularly if pain in the region of the ovarian tumor 
and signs of local inflammation exist is an early removal imperative. 
We prefer at present the abdominal operation. In the last edition of 
this work the removal of small ovarian tumors by the vagina was advo- 
cated and described at some length, this method having first been 
recommended and practised by Thomas. It has recently been peiv 
formed a number of times with fair success by Henry T, Byford of 
Chicago, but at the present day there seems no particular reason for 
substituting another form of ovariotomy for that by abdominal section, 
which answers every purpose, both as to facility of operation and cer- 
tainty of result. Hence vaginal ovariotomy, while perfectly feasible, 
and indeed not particularly difficult or dangerous, can scarcely be said 
to be the favorite operation at present. The reason for this may be 
the limited field through which the operator is obliged to work, and the 
ever-present uncertainty, before the peritoneal cavity is opened, whether 
it is possible to remove the tumor by the vagina or not. Extensive 
adhesions, for instance, might prove an insuperable obstacle to the com- 
pletion of the operation, and would necessitate an additional abdominal 
section. 

In former days the mental condition of the patient was supposed to 
influence very decidedly the result of an ovariotomy. Undoubtedly, a 
woman with a cheerful disposition, who has made up her mind to 
recover, stands a better chance than one who either does not care or is 
convinced that she is going to die ; but we have seen even patients with 
the latter frame of mind recover without any drawback whatever ; hence 
the mental disposition of the patient is at the present day not regarded 
with as much apprehension or anxiety as formerly. A nervous, excit- 
able state of mind, which induces the patient to fret and worry con- 
stantly about the presence of an ovarian tumor and the possibility of 
an impending operation, would induce us to advise as early a -removal 
of the tumor, and with it the cause of the mental disturbance, as pos- 
sible. But this would only be an additional reason for an early opera- 
tion, the true reason being the actual presence of an appreciable ovarian 
tumor. The older operators laid great stress upon the effect of the 
general health of the patient on the prognosis of the operation. Thus, 
some believed that as long as the woman was strong and showed no 
constitutional effect of the tumor an operation should not be performed, 
because it would be more likely to be followed by inflammatory reac- 
tion — that is to say, peritonitis ; hence they waited until emaciation of 
the patient had progressed to an extent which in many cases undoubt- 
edly rendered her incapable to rally from the shock of the operation. 
Their idea was that the pressure produced by the growing tumor ren- 
dered the peritoneum tough and little disposed to inflammation. Of 
course it is understood that the depreciation of the general health must 
be due only to the cachectic influence of the ovarian tumor, not to 
organic disease of heart, kidneys, liver, or other vital organs. We 



ABDOMINAL OVARIOTOMY. 717 

know now that nothing is gained by allowing a woman's general health 
to deteriorate under the painful influence of a large ovarian tumor, 
since there is no more danger of peritonitis under proper antiseptic and 
antiphlogistic precautions in the early stages of the disease than there 
is gained in waiting until the system has become debilitated and the 
peritoneum toughened by the growth of the tumor. Statistics of 299 
cases collected by Dr. J. Clay at a time when this delay was still prac- 
tised show that the results of the operation in patients whose health 
was still good, and in others where it was impaired, are very nearly 
equal. 

The greater amount of solid matter in an ovarian tumor to a certain 
extent influences the rapidity and difficulty of the operation, and there- 
fore also the chances of recovery : but this influence is relatively slight 
when compared with the presence of extensive adhesions, chiefly to 
vital organs, such as intestines and liver, and the general condition of 
the patient. It may be accepted as an unquestioned rule that the 
stronger the patient, the better her general health, and the less debili- 
tated she is either by the tumor or by disease of other organs, the 
better, cceteris paribus, no matter what the complications may be, her 
chances for recovery. 

Conditions Unfavorable to the Operation. — The following circum- 
stances, although unfavorable to the operation, do not contraindicate it 
unless they exist in the most exaggerated degree : 

Obscurity as to diagnosis ; 

Great constitutional impairment ; 

Extensive and firm adhesions to viscera ; 

Complication with other diseases (kidneys, liver, heart, and 
lungs); 

Great thickness of abdominal walls. 

Abdominal Ovariotomy. 

As is the case with many other operations, each surgeon has his 
own peculiar method, and no two operators quite agree in all the 
details of the operation. It is manifestly impossible for us to repro- 
duce the method of each operator, differing as each does very often 
only in minor points. We have therefore decided to describe the ope- 
ration of ovariotomy as we do it ourselves, and as we think it is per- 
formed substantially by the majority of abdominal surgeons. 

Preparatory Treatment. — As soon as the presence of an ovarian 
tumor is discovered and an operation decided upon, as early a date as 
possible should be fixed. In the mean time, the general health of the 
patient should be attended to, her bowels regulated, tonics such as iron 
and quinine prescribed if necessary, daily tepid baths taken in order 
to increase the activity of the skin, open-air exercise advised in accord- 
ance with the patient's strength, and everything needed be done to tit 
her for the ordeal which she is to undergo. Her mind should be set at 
rest by informing her that her chances for recovery arc exceedingly 
good, and that she need be in no anxiety about the success of the ope- 
ration ; and her friends should be enjoined to share this feeling if they 



718 OVARIOTOMY. 

can, or at all events impress the patient to that effect. Of course, the 
time intervening between the discovery of the tumor and the date fixed 
for the operation will usually be short, since at the present day long 
and unnecessary delays in removing the tumor are considered inadvis- 
able in consequence of the possible accidents which may occur at any 
time without the slightest warning in every case of ovarian cyst. 
These have already been referred to, and we will merely repeat that 
they consist in twisting of the pedicle, inflammation and suppuration 
of the cyst, peritonitis, and adhesions. Therefore very little oppor- 
tunity will generally be given to carry out the above tonic rules ; still, 
usually a few days to a week will elapse, and this time will be sufficient 
to at least regulate the boAvels and act favorably upon the skin. 

Formerly it w T as thought best to select a clear, dry, and bright day 
for the operation, neither too hot nor too cold ; and this was considered 
quite a serious matter. At present very little importance is attached 
to the kind of weather which may happen to prevail on the day chosen 
for the operation. Of course, a bright day is preferable to a dark day, 
but simply because* the operator can see better by a bright sunlight. 
As far as the recovery of the patient is concerned, the weather seems 
to bear no influence. This may be accounted for by the practice of 
keeping the operating room at as nearly an equable temperature, 
between 70° and 75° F., as possible, no matter what the weather may 
be outside. The time of year at which an ovariotomy is performed is 
also of no special consequence, with the sole exception that when the 
weather is very hot the operation, as well as all other operations of 
election — that is to say, that are not urgent — had better be postponed 
until cooler weather, simply because confinement to bed during great 
heat is irksome to the patient, and by interfering with her comfort may 
disturb her convalescence. Some months of the year, such as March 
and April, in which in our climate there is a great deal of moisture 
from the melting snow and the frequent rains, have also been supposed 
to be unfavorable to convalescence from capital operations ; this w T e 
believe, however, to be a fallacy. As regards the time of day at which 
an ovariotomy should be performed, the convenience and leisure of the 
surgeon have to decide. The Germans prefer operating early in the 
morning, before the labors of the day have to a certain extent brought 
on both physical and mental fatigue. Besides, fresh from his bed and 
from a bath, the surgeon may be said to be absolutely aseptic. In 
England and this country, however, a later hour in the day is chosen, 
simply, we think, because more convenient to the surgeon, and the 
latter, taking the same antiseptic precautions as his German brother, 
has practically equally good results. 

It was formerly believed, and many operators still think, that the 
proximity of the menstrual period is a counter-indication to the per- 
formance of ovariotomy or indeed of any operation on the female sexual 
organs. While this is undoubtedly correct, so far as it applies to an 
operation on parts with which the menstrual blood comes in contact, it 
does not hold good in abdominal sections, which do quite as well when 
performed immediately before or even during the menstrual period as 
at other times. T\ r e have repeatedly found ourselves obliged to do an 



A N AESTHETIC— OPERA TING R OM. 



719 



Fig. 311. 



ovariotomy or remove the diseased ovaries and tubes on the very day 
when unexpectedly menstruation had set in, the operation having 
already been announced and prepared for, and in no case do we 
remember having to regret such action. The only exception to this 
statement might be the operation for removal of fibroids by abdominal 
hysterectomy, when the greater hyperemia of the parts might possibly 
produce hemorrhage which would not at other times take place. The 
only precaution to be observed is to cover the vulva with a bichloride 
pad, so as to prevent any possible infection of the abdominal wound 
from the menstrual blood. 

Anaesthetic. — The choice of the anaesthetic to be used in ovariotomy 
depends on the predilection of the operator and upon the condition of 
the heart and kidneys. The favorite anaesthetic in this country is sul- 
phuric ether ; in England, chloroform, ether, and the bichloride of 
methylene are employed ; in Germany and France, almost exclusively 
chloroform. Some operators use the triple mixture of ether, chloro- 
form, and alcohol, equal parts. We ourselves prefer ether for the 
majority of cases, but our choice between ether and chloroform will be 
decided by the results of the examination of the urine and of the heart. 
If there is any evidence of renal disease, as shown by the presence of 
albumin or casts, ether should be avoided and chloroform employed. 
Further, if there is any bron- 
chial irritation or sign of chronic 
pulmonary disease, ether should 
be avoided. We believe that 
we have seen acute bronchitis 
and even pneumonia produced 
by ether anaesthesia. If the 
heart is found weak, flabby, 
its pulsations feeble and inter- 
mittent, chloroform should be 
avoided, and ether, which is a 
heart stimulant, administered. 
It must be left to the judgment 
of the physician who adminis- 
ters the anaesthetic whether he 
thinks it wise to change from 
ether to chloroform or the re- 
verse during an operation. We 
do not think it best to aid the 
anaesthetic by the previous administration of a hypodermic of morphine 
in any abdominal section, as we might do in other operations. Our 
reason for not wishing to give morphine in an abdominal section is. 
that it tends to check peristaltic action of the intestines and interfere 
with our efforts to move the bowels soon after the operation. 

Operating .Room. — In public and private hospitals ovariotomies will 
usually be performed in the general operating room, or even in a room 
specially reserved for abdominal sections. This room will of course be 
fitted up in such a manner as to enable it to be rendered easily and 
thoroughly aseptic, the walls, ceiling, and floor being of impermeable 

46 




Clover's Ether Inhaler. 



720 OVARIOTOMY. 

material which can be scrubbed and drenched with disinfectants with- 
out affecting its integrity. In private houses the room selected for an 
abdominal section should be prepared for the operation by removing 
the carpets, hangings, curtains, and all movable furniture ; by scrub- 
bing the walls, floor, and ceiling thoroughly with a 1 : 2000 bichloride 
solution, and by fumigating the night before with sulphur. If all these 
precautions are taken, abdominal sections can be performed with as 
much safety in the general operating room of a public hospital or in 
private houses as they can in rooms specially reserved for that ope- 
ration. 

Instruments, Sponges, Gauze, etc. — The instruments required for 
an ovariotomy may briefly be summed up as follows : 
1 sharp-pointed bistoury ; 

1 straight blunt-pointed bistoury ; 

2 mouse-tooth forceps ; 

2 straight or slightly curved blunt-pointed scissors ; 
1 dozen artery forceps ; 

3 long double vulsella forceps ; 

At least 6 long straight pressure forceps (Tait's) ; 
3 flat grooved pressure forceps (pince cremaillere) ; 

1 cautery pedicle clamp ; 

2 long blunt-pointed pedicle needles (Deschamps') ; one straight, 

the other curved at right anodes ; 
At least 6 long, straight, curved needles for the abdominal 

sutures ; 
Plenty of strong braided or twisted silk, strong catgut, and 

strong silkworm gut. 
At least a dozen sponges, prepared and sterilized, of the size of an egg, 
for use on an equal number of metal sponge-holders. Further, at least 
a half dozen larger sponges, similarly prepared, for use with the hand. 
Then three or four large flat sponges, at least a foot square, also 
thoroughly sterilized, to be used in holding back the protruding intes- 
tines or protecting the abdominal cavity while introducing the closing 
stitches. [I have for a number of years entirely dispensed with these 
large flat sponges, finding them difficult to keep clean and liable to be 
rendered friable by the repeated sterilizing process, in consequence of 
which pieces were liable to be torn off and possibly left behind in the 
abdominal cavity. To use new sponges of this size at each operation 
was rather expensive, hence I have substituted for them pads six inches 
long by four inches Avide formed of thoroughly sterilized cheese-cloth 
or gauze, with strings attached, which are destroyed after each opera- 
tion. These are cheap, can be supplied readily at short notice, and 
answer every purpose for which I formerly employed sponges. — P. F. M.] 
The numbers of sponges on holders, loose sponges, and pads of gauze 
are to be counted and marked on a blackboard or on a piece of paper 
in plain sight before the operation, and these figures must tally with 
the several articles on hand before the abdominal cavity is closed. The 
same rule applies to the instruments. In this way the anxiety of 
accounting for a missing sponge, forceps, or other instrument can easily 
be prevented, and a search for the missing article, possibly in the 



ASSISTANTS. 721 

already closed abdominal cavity, rendered unnecessary. We need but 
mention that sponges and artery forceps have been repeatedly forgotten 
in the abdominal cavity, sometimes to the fatal detriment of the patient, 
at other times, curious to say, being discharged in course of time by 
suppuration, with eventual recovery. A number of agate-ware basins 
for keeping sponges, towels, pads, and for the reception of the cyst 
fluid, should be on hand. Further, plenty of boiled water which has 
thus been sterilized, and which should be kept warm on a gas or oil 
stove ; also a gallon of Thiersch's solution (salicylic acid, 1 part ; 
boracic acid, 4 parts ; to 1000 parts of water). 

It should be specially noted that no sponges, gauze pads, or towels 
which are to be used in contact with the wound or introduced into the 
abdominal cavity should be soaked in a solution of bichloride, no matter 
how weak ; neither should any solution containing that chemical be 
poured into the abdominal cavity. The bichloride solution used in 
sterilizing the sponges, pads, etc. is washed out in hot water just before 
the operation ; hence there is no danger of constitutional mercurial 
affection. 1 

A Paquelin thermo-cautery, which should have been tested just 
before the operation, should be in readiness, the tip which we generally 
use being the flat, slightly curved knife. 

Operating Table. — Any plain, thoroughly cleansed, and asepticized 
board table will answer for the operation. It should of course be of 
sufficient length to hold either the whole figure of the patient from top 
to toe, or at all events from vertex to knees, the feet being allowed to 
rest on a chair. There are numerous more or less complicated operating 
tables in the market, devised by different surgeons. The simplest and 
most easy to keep clean is probably that of Frau Horn, the matron of 
A. Martin in Berlin, which is made of galvanized iron, and is merely 
a skeleton, the centre-piece being removable in order to permit the 
application of the circular bandage after the operation. It is not worth 
while to go into details on this subject, since he who is not satisfied 
with the plain deal table referred to will probably construct one to suit 
his own fancy. The foot of the table may be elevated by putting two 
blocks under the legs of any height desired. The object of this is to 
elevate the pelvis, and it will be found a very useful position in many 
cases of abdominal section where it is desired to remove the intestines 
by gravitation from the pelvic brim and the field of operation in order 
to lay the latter bare for inspection and manipulation. This position, 
in a much more exaggerated degree, was first devised by Trendelenburg, 
now professor in Bonn, for suprapubic cystotomy operations, and he has 
had a special table made for this purpose. 

Assistants. — While it is desirable to have as few outsiders in a lapa- 
rotomy room as is consistent with the successful performance of the 
operation, it really makes very little difference nowadays how many are 
present, provided all carefully observe the antiseptic precautions with- 
out which no surgical operation is now performed. We prefer to have 
three assistants, without whom we think the operation is likely to be 

' For details as to aseptic preparation of sponges, ete. we refer to the section on 
Therapeutic Resources, p. 62. 



722 



OVARIOTOMY. 



delayed : one gives the anaesthetic (and we might here remark that an 
experienced man, no young beginner, should be chosen for this office) ; 
another, who is the chief assistant, stands opposite the operator and 
helps him during the various steps of the operation ; and the third hands 
the instruments, threads the needles, and guards all that appertains to 
this part of the operation. In addition there are two nurses required, 
one of whom washes and hands the sponges to the operator or his first 
assistant; the other changes the water for the sponges, passes the boiled 
water or Thiersch's solution when required, and makes herself generally 
useful. It is this nurse who, in the absence of a convenient spectator, 
can be taught to prepare the Paquelin thermo-cautery and hands it to 
the operator when the time comes to use it. Operator, assistants, and 
nurses should all have rendered themselves thoroughly aseptic on the 
day of operation, should have taken a warm soap-bath, on that morn- 
ing, if necessary using sublimate solution 1 : 2000 to remove any pos- 
sible infection with which they may have come in contact during the 
previous twenty-four hours. They should have a complete change of 
linen and clothes, which are either entirely fresh from the wash or have 
never been exposed to septic infection. Their finger-nails should be 
trimmed short and smooth and thoroughly cleansed just before the 
operation ; each participant in it scrubs his or her hands and forearms 
up above the elbow first with soap, and then immerses them in a solution 
of bichloride of mercury 1 : 1000. After any accidental contact with 

Fig. 312. 




Position of Patient, Operator, and Assistants in Ovariotomy, 
operator; B, first assistant; C, anassthetizer ; D, assistant for instruments ; E, table for instruments; G, 
nurse ; F, table for sponges, gauze pads, towels, etc. ; H, basin of 1 :1000 bichloride solution for hands 
of operator ; 7, window. (The operating table and all persons and articles in this cut should have been 
placod nearer the window.) 



an object not thus sterilized, such as the clothes of a spectator, the 
operator's own head, etc., the hands should be immediately bathed in 
the bichloride solution before proceeding with the operation. Any 



INCISION. 72Z 

instrument, sponge, etc. accidentally dropped upon the floor during the 
operation is not to be used again on that day unless first thoroughly 
scrubbed and disinfected. 

Position of Patient, Operator, Assistants, etc. — The patient lies at 
her full length on the table if of sufficient length, or, if not, with her 
feet supported by a chair. The operator stands on the right hand of 
the patient, facing her head. The first assistant stands on the opposite 
side, facing the operator. The table containing the instruments, which 
are placed in flat porcelain or agate-ware trays covered with a 3 per 
cent, solution of carbolic acid, stands on the right hand of the operator 
at the foot of the operating table. To the right or left hand of the ope- 
rator, on a small stool, stands an agate-ware basin containing a solution 
of 1 : 1000 bichloride, into which the operator dips his hands as often as 
he thinks they need cleansing during the operation. Some operators 
occupy a different position from the one described. The late Prof. 
Schroeder stood on the left side of the patient, facing her feet, and 
made the incision from the pubes upward toAvard the umbilicus ; Martin 
sits on a Ioav stool between the separated thighs of the patient, and 
operates in this position ; but the majority of operators occupy the 
place Avhich we have described. The patient, Avho has received a Avarm 
bath on the morning of the day of operation, in Avhich she was thoroughly 
scrubbed, and perhaps even washed off Avith a 1 : 10,000 solution of 
bichloride, and whose bowels have been thoroughly moved for several 
days previously by laxatives, but by enema only on the morning of 
the operation, is placed upon the table, and her abdomen is thoroughly 
scrubbed, first with soap and then Avith a 1 : 2000 bichloride solution 
and dried. Then a solution of iodoform in ether is poured over the 
lower part of the abdomen, care being taken to fill the umbilical fossa 
Avith it, so as to disinfect this portion most thoroughly. The abdomen 
is surrounded by warm wet towels wrung out of a 1 : 1000 bichloride 
solution, so as to leave a square area of skin exposed. The pubes, 
Avhich have been shaved, are covered with especial care. The bladder, 
Avhich has been emptied either voluntarily or by catheter just before 
the operation, is noAv sounded in order to ascertain whether it has pos- 
sibly been draAvn up on the anterior Avail of the cyst by adhesions and 
brought in the line of the usual incision. An avoidance of this pre- 
caution has more than once resulted in the bladder being opened under 
the mistaken idea that it Avas the peritoneum. 

Incision. — The point chosen for the incision is usually midway 
between the umbilicus and the symphysis pubis in the median line. 
The operator seizes a sharp-pointed bistoury, and, carefully following 
the linea alba, makes an incision about tAvo inches long down to the 
fascia of the recti muscles. It is not necessary to dissect step by step 
through the fat doAvn to the muscle, as has formerly been recommended. 
Bleeding arteries are frequently met with during this first step, and 
should either be at once caught up and tied with catgut or compressed 
with artery forceps, which can be removed before the peritoneal cavity 
is opened, when the smaller vessels Avill probably have ceased bleeding. 
The fascia of the recti muscles is now caught up by the operator and 
his assistant, each with a mouse-tooth forceps, and incised between the 



724 OVARIOTOMY. 

two. If lucky, the aponeurosis of the muscles is at once discovered 
and carefully divided clown to the supraperitoneal fat. We say " if 
lucky," because we know of no sure guide by which that aponeurosis 
can always be found at the first stroke. It has been our experience 
that, standing on the right side as we do, we have usually, when we 
failed to find it at once, gone a little too far to the left, and hence 
on searching toward the right we have easily discovered it. It is of 
advantage to make the incision through the aponeurosis rather than 
through the fibres of the rectus muscle, since the latter are more liable 
to bleed and be torn by the inevitable manipulations during the rest of 
the operation. After reaching the supraperitoneal fat, this is lifted up 
by mouse-tooth forceps and drawn gently to one side, and then will 
appear the glistening pink peritoneum, which should be very carefully 
and superficially elevated by the forceps held by the . operator, and 
grasped at about half an inch distance by another forceps held by the 
assistant. Between these two the peritoneum is then very carefully 
nicked, having been drawn up out of the incision, so that by trans- 
mitted light the operator can see whether he has carried up intestine or 
omentum which may chance to be adherent to that point or have fol- 
lowed the lifting up of the peritoneum. Often the peritoneal cavity is 
opened by one nick of the knife, but quite as frequently, especially if 
there has been chronic peritonitis, layer after layer has to be divided 
with the greatest precaution, and, we confess on our part, usually with 
some anxiety, before finally the cavity is opened. 

The older operators recommended the use of the grooved director in 
making the abdominal incision, dividing each layer of fat, fascia, and 
finally the peritoneum on the director, but we have ceased using that 
instrument for a number of years, finding it quite unnecessary if the 
precautions just described are observed. The steps and difficulties of 
opening the peritoneal cavity which we have just enumerated apply 
perhaps rather more to that operation when there is no distension of 
the abdominal cavity, as is usually the case when an ovarian tumor is 
to be removed. In the latter instance this first step of the operation is 
usually very much facilitated, because the distended abdominal walls 
are much thinner, there is generally very little fat, and the peritoneum 
is not thickened except when chronic peritonitis has prevailed. It 
usually takes scarcely a minute to open the abdominal cavity in large 
ovarian tumors, whereas in a difficult case of rigid, fat abdominal walls 
without distension of the cavity five or six minutes of careful dissection 
may elapse before the peritoneum is finally nicked. Any operator who 
has accidentally injured the intestine by hasty incision of the perito- 
neum will readily appreciate the necessity for the precautions which w r e 
have enumerated. 

Before opening the peritoneal cavity it is well to stop all hemorrhage 
from the walls of the incision by tying bleeding vessels with catgut, and 
it is also advisable to remove all artery forceps lying in the wound 
which might be in the way or possibly slip into the abdominal cavity. 

An error which has occurred to several experienced operators is that 
the peritoneum, being thickened by chronic inflammation, was mistaken 
for the adherent sac of the tumor, and after apparently incising the 



OPERATION. 725 

peritoneum, which presented several layers as already described, the 
operator proceeded to peel loose, as he thought, the adherent cyst-wall . 
from the adjacent parietal peritoneum, not discovering his error until 
he had peeled loose a foot or more of the peritoneum from its attach- 
ment to the inner surface of the muscles. This mistake really ought 
not to occur if the operator is careful to ascertain whether he is in the 
peritoneal cavity or not by following up the division of each layer with 
his finger, and not resting satisfied that he has opened the peritoneal 
cavity until his finger assures him of that fact. At times the whole 
cyst may be so adherent to the peritoneum of the abdominal walls that 
it cannot be detached, and then probably the knife, preceded by the 
finger, will open the cavity of the cyst and speedily discover the true 
nature of the case. It is always wise to percuss the anterior abdominal 
wall before beginning the incision, and certainly before opening the 
peritoneum, in order to avoid injuring the intestine, which, although it 
does not belong there, may possibly be adherent to the anterior cyst- 
wall. 

The danger of injuring the bladder w r e have already referred to, and 
how it can be avoided. The bladder is sometimes pushed up by an 
intrapelvic ovarian tumor without being adherent. Such was the case 
recently in an operation performed by Munde, where the previous sound- 
ing of the bladder had been overlooked, and only a very careful dissection 
and extension upward of the incision and opening the peritoneal cavity 
there saved the bladder. The peritoneum, when thickened by chronic 
inflammation, is often easily stripped from its muscular attachment, and 
especially if the abdominal walls are very thick or rigid we have found 
it a useful device to pass a temporary suture through each lip of the 
wound, tying it and leaving the ends long, for the purpose not only of 
preventing this detachment of the peritoneum, but also in order to use 
these sutures as retractors in case of need. 

Operation. — The steps of the operation are the following: 
1st. Incision through abdominal walls; 
2d. Tapping tumor ; 
3d. Removal of the sac; 
4th. Securing the pedicle ; 
5th. Cleansing the peritoneum ; 
6th. Establishing drainage, if necessary; 
7th. Closing abdominal w T ound ; 
8th. Applying antiseptic dressing. 
As a rule, the shorter the abdominal incision the better for the after 
progress of the case. 

Baker Brown laid down, years ago, in reference to abdominal sec- 
tion, this important rule : it should always be regarded originally as an 
explorative incision. If any condition contraindicating the removal of 
the sac be found tp exist, it may then be closed without exposure of the 
patient to great danger, while if it be found advisable to enlarge it to 
proceed, this may be done to any necessary extent. Even large mono- 
cysts may be removed through a small incision, not longer than one 
inch and a half. The great dread which has always been entertained 
of cutting into and exposing the peritoneum lends a degree of fascina- 



726 OVARIOTOMY. 

tion to the short incision. But at present we no longer fear to incise 
or expose the peritoneum, knowing that our scrupulous antiseptic pre- 
cautions guard against septic infection : and when it is borne in mind 
that, for want of a sufficiently free incision, a tumor is often slowly and 
clumsily removed, bleeding vessels not detached, and an unclean peri- 
toneum closed up in place of a clean one, it will be recognized that an 
operator may err in this direction as well as in the other. 

No universal rule exists as to a long or a short incision, most ope- 
rators being guided by the necessities of each case. The Germans 
usually make long incisions, the English prefer them short, and the 
Americans follow the plan first suggested by Baker Brown, to begin 
with a small incision and to enlarge it if necessary. It is not the 
length of the incision that is to be feared, but when unnecessary to 
clean and thorough operating there certainly is no use .in prolonging 
the operation by making an opening which calls for lengthy stitching 
and predisposes the patient to the danger of subsequent ventral hernia. 

The results of Sir Spencer Wells, as embodied in the following 
table, prove, however, that short incisions are greatly to be preferred 
to long ones : 

No. of cases. Recoveries. Deaths. Mortality. 

Not exceeding 6 in., 440 337 J 03 23.4 per cent. 

Exceeding 6 in., 60 36 24 40 " " 

It is equally worthy of note that the same surgeon operated on 17 cases 
by an incision of three inches, and lost 23.53 per cent., and on 203 
cases by an incision of five inches, and lost 19.7 per cent. 

The most rational deduction to be drawn from these facts is this : 
that the shorter the incision by which the sac can be removed " tuto, 
cito, et jucunde," the better for prognosis. The effort to remove the 
sac, however, through an opening so small as to involve delay, uncer- 
tainty, and inefficient manipulation gives the patient a poorer prospect 
for recovery than the making of a longer incision would offer. 

The shining Avail of the cyst, which is recognized by its pearly- 
white, mottled appearance, being now under the fingers and eyes of the 
operator, he has an opportunity of verifying his diagnosis by palpation, 
visual examination, and removal of fluid by a very small trocar and 
canula or by the needle of the hypodermic syringe. Should connection 
with the uterus be suspected, before proceeding farther its relations to 
this organ should be determined by passing the uterine sound, and 
rotating the uterus while two fingers are passed through the abdominal 
wound down to the fundus uteri. 

Before this, however, the operator may be checked in his progress 
by discovering that he is not in contact with the cyst-wall, although 
the peritoneum be opened. In place of the smooth, shining wall of the 
cyst, he discovers a vascular membrane containing large vessels which 
spreads over the tumor like an apron. To one who has never seen this 
covering it will prove very perplexing. It consists of the peritoneal 
walls or roof of the broad ligaments, which have been spread out by 
the growing tumor and have undergone great hypertrophy. Tumors 
thus surrounded have, according to our experience, broad and short 



TAPPING. 727 

pedicles, and their extirpation will be very difficult unless the valuable 
method advised by Dr. Miner of Buffalo be adopted. It consists in 
cutting through the envelope of the cyst, avoiding as far as possible 
the opening of large vessels, introducing the fingers, and enucleating 
the tumor. 1 The sac which is left should then be opened, thoroughly 
cleansed, touched all over its oozing surface with solution of persul- 
phate of iron, and if large tied around a drainage-tube. If the sac 
cannot be enucleated, as much of it with its peritoneal envelope as can 
be drawn out of the abdominal cavity should be removed close to the 
abdominal wound, and its edges sewed to the edges of the incision. 
The cavity after careful cleansing should be packed with iodoform gauze. 
Further reference to these cysts will be made later on. 

Should any doubt exist in the mind of the operator whether the 
structure which he sees through the incision is really the cyst-wall or 
the peritoneum covering it, he may endeavor to pass a finger thoroughly 
washed in carbolized water between the cyst and peritoneum, or a steel 
sound may be gently swept around if it be possible. We usually 
employ a large (Peaslee's) sound for the purpose of detecting adhesions, 
which, if thin and loosely attached, may be broken by the sound as it 
is carried around the cyst ; if thick, we are prepared to deal with them 
by ligature and division as they come in view during the delivery of 
the cyst. 

Tapping. — [Before tapping it is my habit to turn the patient on the 
side toward the operator, whose special attention at this moment should 
be directed to two objects — one preventing the escape of even one 
drop of fluid into the peritoneal cavity ; the other the avoidance, as far 
as possible, of the introduction of his hands or fingers into it. Turn- 
ing the patient on the side greatly facilitates the second of these, and 
by no means increases the difficulties of the first. The assistant oppo- 
site the operator, now standing at the back of the patient, steadies her 
body with his right hand, while with his left he presses a soft, carbol- 
ized towel or sponge firmly against the abdominal wall just below the 
incision, so as to prevent ingress of fluid to the peritoneal cavity. The 
operator should now thoroughly cover the raw lips of the wound with 
carbolized vaseline or some other unctuous substance to prevent absorp- 
tion of the colloid, perhaps the decomposing, purulent fluid of the sac, 
which is now to be tapped and withdrawn. — T. G. T.] [While no objec- 
tion can be made to this practice of turning the patient on the side before 
and during the tapping of the cyst, it is now followed by very few 
operators, simply because it is not necessary. By careful compression 
of the abdominal Avails to the cyst as the fluid escapes, by speedy trac- 
tion on the cyst-wall with vulsella, so as to keep the opening in the 
cyst well out of the abdominal incision, by enlarging the opening in the 
cyst, and by protecting the lower angle of the wound by towels, no 
fluid can possibly enter the abdominal cavity with the patient in the 
dorsal position. I have not practised the change to the lateral posi- 

1 We have resorted to this method a great many times, with good results, in eases 
which would have proved unmanageable by other means. It appears to us to be one 
of the most valuable of all the contributions 10 ovariotomy which have emanated from 
this country. 



728 OVARIOTOMY. 

tion for years. Besides, we now no longer fear the entrance of ovarian 
fluid into the abdominal cavity, for we know that it is not poisonous, 
and that we can easily wash out what little may accidentally get in. 
I do not wish to be understood, however, that I would not use every 
precaution to prevent its entrance ; but should any accidentally enter 
I should not consider it a great misfortune or a serious danger to 
recovery.— P. F. M.] 

With a long curved trocar and canula, such as that shown in Fig. 
313, the fluid of the sac is now allowed to flow away if it be not too 
tenacious to do so. 

Fig. 313. 




Emmet's Trocar and Canula for Tapping Cyst. 

We have cast aside entirely, and would advise others to do so, the cum- 
brous attachments to trocars intended to carry off the fluid of the sac 
without soiling the surroundings of the patient. If a large wash-tub 
be placed upon the floor, and a little skill and care be displayed by the 
operator, no necessity for them will be found to exist. Or the fluid 
may be caught in basins held under the protruding cyst. 

Let us suppose that the sac contents flow away easily and freely ; the 
operator should wait until the visible portion of the sac protrudes a 
little through the abdominal opening ; then he should fix a vulsella 
forceps in it and draw the opening in which rests the canula just beyond 
the abdominal wound. In a few minutes a second vulsella should be 
fixed in the sac, and very soon it will protrude decidedly. As soon as 
it is outside the abdomen, the canula may be with advantage withdrawn, 
and a free opening made into the sac by a pair of scissors, to prevent 
the waste of time which would attend its slow evacuation through the 
canula. 

If one sac be emptied and another be felt, the operator may intro- 
duce the trocar into the canula, turn this obliquely, and plunge it into 
the remaining cyst or cysts ; or he may — and this is usually safer and 
better — pass one or two fingers or the entire hand into the main sac 
and rupture the remaining ones in this way, and allow their contents 
to flow out. In doing this the hand should never be passed into the 
peritoneal cavity, and great care should be observed not to break any 
remaining cyst so as to let it communicate with that cavity. This 



REMOVAL OF THE SAC. 729 

manoeuvre is a very important and effectual one, and withal a very 
safe one, since the cyst-walls protect the peritoneal cavity thoroughly. 
It is far safer than the plan of plunging a trocar and canula blindly 
about in search of cysts, and than that of passing the hand into the 
peritoneal cavity to find them. 

While the fluid is pouring out, compression of the abdominal walls 
against the tumor should be made by an assistant, who places one hand 
on each side of the abdominal incision, and the sac should be kept 
from slipping into the abdomen by strong forceps made to grasp its 
lips if an ordinary canula be employed. 

Suppose, however, that the fluid of the cyst is semi-solid colloid, 
that numerous very small cysts exist, or that a large amount of solid 
material prevents evacuation of the tumor by trocar ; what then is to 
be done? Seizing the tumor with two large and strong vulsella at the 
extreme upper and lower extremities of the abdominal wound, and 
holding it firmly against it, the surface of the tumor between these 
vulsella should be cut through, and one finger, then two, and then the 
whole hand, introduced, breaking up as it goes little cysts, and at once 
evacuating their contents. When the hand has well entered the tumor 
a species of "conjoined manipulation," one hand on the abdomen and 
the other in the tumor, will serve to reveal the presence of all cysts 
not yet evacuated. 

In this way immense tumors may be delivered without introducing 
the hand into the peritoneal cavity, without making a long abdominal 
incision, and without allowing the escape of sac-contents within the 
abdomen. 

Removal of the Sac. — The sac, being now drawn out by the tooth- 
forceps, vulsella, or pincers, which have been fixed in it to prevent its 
escape into the abdomen, is seized by the fingers of the operator and 
gently drawn forth through the incision. This is the time for breaking 
adhesions, and this is best done, as a rule, by steady traction upon the 
sac. In the large majority of cases traction, steady and even powerful 
traction, upon the sac is the best, most rapid, and safest method of sev- 
ering attachments. Of course, this must not be rash or intemperate in 
degree, for by that serious damage might be done ; but it should be so 
firm and decided as to break all ordinary attachments. 

Adhesions of the wall of the cyst to neighboring organs are very 
common, and usually more or less unsuspected. The most common 
adhesions are between cyst-wall and abdominal wall, omentum, large 
intestine, and its mesentery. Less common, fortunately, are those 
between long loops of small intestine, bladder, liver, diaphragm, and 
walls of the pelvic cavity. 

If the delivery of the sac is restrained by adhesions of sufficient 
firmness as not to tear as the attempt is made to draw them out of the 
abdominal cavity, if necessary the incision should be enlarged, and in 
any case the adhesion fully exposed, and, if thick, tied in two places 
with strong cat<mt or silk and severed between. Thin, flat, filmy 
adhesions can be detached by gentle teasing with the finger-nail or 
pushing with a wet sponge. But, of course, no bleeding point should 
be loft unligated. Adhesions to the intestines are bv all odds the most 



730 OVARIOTOMY. 

troublesome and dangerous to ligate and detach. Occasionally the peri- 
toneal coat of the gut is injured during the treatment or separation, 
and requires to be sewed by fine catgut or silk sutures. The lumen 
of the intestine has even been accidentally torn into on such occasions. 
At times it may be necessary to leave a piece of the cyst-wall attached 
to the organ to which the cyst was adherent ; it is well, in that case, to 
prevent the possibility of a re-formation of the cyst by peeling off the 
secreting surface of the adherent piece. 

Sometimes, instead of adhesions here and there, the cyst is found 
universally attached over the pelvis, and the operator sees cause to fear 
lest the removal of the whole cyst may prove impracticable. This con- 
dition of things may be dealt with in one of two ways : The operator 
may strip the envelopes of the sac away from it about three inches 
above the attached surface, and enucleate its lower segment ; or if he 
find this impossible, or deem it to be very hazardous on account of 
hemorrhage, he may pass into the extremity of the sac a glass drain- 
age-tube, tie the sac firmly around this, and, fixing both sac and tube 
between the lips of the abdominal wound, drain it and inject with car- 
bolized fluid ; or, as is now done most commonly, pack it with iodoform 
gauze. 

There are little manoeuvres which experience will teach the operator 
which will greatly assist in removal of the sac from the abdomen when 
difficulties present themselves. One of these, which we learned of Sir 
Spencer Wells, consists in ignoring the attachments at the upper part 
of the sac, seizing its lowest, inner portion, pulling this out through its 
mouth, and thus completely inverting it. Another consists in ligating 
the tumor, when much solid matter exists at its lower extremity, before 
complete emptying of it, turning it over, and delivering the pelvic 
extremity first. A third plan is applicable when the upper portion of 
the tumor is fluid and that below the umbilicus solid, and consists in 
passing the long trocar through the solid portion obliquely upward, 
emptying the upper sac, pulling this down and out first, and then 
dragging out the solid portion near the pelvis. By adopting these 
methods in suitable cases it is surprising to see through how short an 
incision a colossal and semi-solid tumor may be extracted. [Some years 
ago I removed one in the Woman's Hospital weighing over sixty pounds 
through an opening of less than five inches. — T. G. T.] 

The tumor, being freed from attachments, is now drawn forth and 
the pedicle seized in the fingers. To prevent the fluid from soiling the 
instruments, and perhaps entering the abdominal cavity, the sac is 
wrapped in a wet aseptic towel, and, if necessary, the towels surround- 
ing the incision replaced by clean ones. We now are in the habit of 
compressing the pedicle with the clamp shown in Fig. 314, and cutting 
off the tumor, in order to have more room for the application of the 
ligature to the pedicle. 

Securing the Pedicle. — Formerly there were several methods in use 
of securing the pedicle, the favorite one being the permanent clamp, 
left on until the stump sloughed away; the next, ligation and 
transfixion with pins in the abdominal incision ; third, ligation and 
dropping into the abdominal cavity ; fourth, temporary clamp and 



SECURING THE PEDICLE. 731 

actual cautery. Of these methods, all have been abandoned except 
two — ligation and dropping, and temporary clamp, ligation, searing off 
portion above clamp with the Paquelin cautery, and dropping. 

According to Dr. Peaslee, the method of ligating the pedicle, cut- 
ting both ligature and pedicle as short as possible, and returning them 

Fig. 314. 




Clamp for Searing the Pedicle in Ovariotomy. 

to the abdomen and closing the abdominal incision, was first popularized 
by Dr. Tyler Smith of London, and as long ago as 1829 by Dr. Rogers 
of this city. Great objection was made to this method for many years, 
the two chief reasons being the danger of slipping of the ligature and 
secondary hemorrhage, and the sloughing of the stump above the 
ligature. Besides, the leaving of a silk ligature in the abdominal 
cavity was thought to be a dangerous proceeding. Hence the appa- 
rently more safe method of fixing the clamped pedicle in the abdominal 
wound, or of keeping it there after the ligation by means of transfixion 
with long needles, was formerly universally adopted. Within the last 
ten years, however, experience has shown us that it is perfectly safe to 
ligate the pedicle and drop it into the abdominal cavity, so long as we 
are careful to tie the ligature so tightly that no subsequent hemorrhage 
can occur. At the present day no other method than the dropping of 
the pedicle is employed, except in the rare instances where the pedicle 
is so short that its constricting ligature encroaches upon the body of 
the uterus, when it may be thought best to protect against possible 
secondary bleeding by uniting the edges of the peritoneal covering of 
the pedicle by interrupted silk or catgut sutures. The objection to the 
dropping of the pedicle thus ligated, that the portion above the ligature 
would become gangrenous, has been shown to be erroneous, since the 
end of the pedicle either becomes attached to some neighboring organ, 
and is thereby nourished, or else an anastomosis takes place between 
the vessels of the peritoneum covering the pedicle above and below the 
ligature. Occasionally the silk ligature produces more or less trouble, 
keeping open a sinus communicating with the abdominal skin, which 
often is not closed until the ligature cuts through and is expelled. The 
ligature usually employed is strong braided or twisted silk, but some 
operators prefer the strongest catgut which can be found in the market. 
The objection to catgut, in our opinion, is the difficulty of drawing it 
to so tight a knot that slipping or loosening is actually impossible. 



732 OVARIOTOMY. 

Still, we are of the impression that in pedicles which are not unusually 
thick or fleshy catgut offers many advantages over silk, since it will 

retain its constricting force for at least a week, which is much longer 

© . © ■- 

than is necessary, and will certainly never give trouble in the future. 
It is very unusual for us to meet with sinuses dependent upon efforts 
of the silk ligature to escape, particularly when the pedicle has been 
dropped and the abdominal wound entirely closed. Only when a 
drainage-tube has been used or very many silk ligatures have been 
applied do we fear trouble from a subsequent discharge of the ligature. 
Metallic ligatures of silver wire are no longer employed in securing the 
pedicle of an ovarian tumor. 

There are different forms of knots in use by various operators for 
ligation of the pedicle. The simplest form is to pass a single thick silk 
ligature through the centre of the pedicle about half an inch below the 
point at which it is intended to sever the pedicle, and to tie first one 
half by a tight double knot, and then carry both ligatures around the 
other half and firmly tie again. For slender pedicles this variety of 
knot would probably answer very well. Another form is to pass a 
double silk ligature through the centre of the pedicle, cut the loop on 
the opposite side, and tie each part separately, carrying one of the 
ligatures entirely around the whole pedicle, and tying again in order to 
prevent possible hemorrhage from the point of puncture. This is the 
usual old form of pedicle ligature by transfixion. The ligature which 
we most frequently use is the one which has been popularized, although 
not invented, by Mr. Lawson Tait, and which is known by the name 
of the Staffordshire knot. The long straight 
Fig. 315. needle with an eye in its point which is used by 

us for transfixion of the ovarian pedicle is 
threaded with a stout silk ligature, so as to form 
a loop on one side, with both ends free on the 
other side of the eye. The pedicle is transfixed 
in the centre, the loop drawn out, and the needle 
Staffordshire Knot. removed. The operator takes care that each free 

strand of the ligature corresponds to its respective 
side of the loop. The loop is then brought over the pedicle toward the 
operator, and one strand is passed through the loop, the other remain- 
ing outside. The strand within the loop is then drawn tight, the other 
strand being held gently, so as to prevent its being pulled through the 
pedicle. As soon as the former strand is tightly drawn the outside 
strand is also drawn as tightly as possible. In this way the pedicle is 
completely compressed, and both strands are then firmly tied by an 
ordinary double knot. This is the real Staffordshire knot. Tait and 
many of his followers consider this knot absolutely safe, and rely upon 
it implicitly for compression of the pedicle. We have thought it wise, 
basing upon a fatal case of slipping after this form of ligation which 
occurred in the practice of Dr. T. A. Emmet (by private information), 
to carry the ligature once more around the pedicle in the same groove 
and to fortify the Staffordshire knot by an additional double knot of 
the ordinary type on the opposite side. This extra amount of silk adds 
nothing to the danger of the operation, and may prevent possible slipping 




SECURING THE PEDICLE. 733 

of the ligature and secondary hemorrhage. Before applying this liga- 
ture, for convenience' sake, if the tumor is very large, we compress the 
pedicle with the clamp shown in Fig. 314 and remove the tumor above. 
This enables us to carry the loop of the Staffordshire knot easily around 
the handles of the clamp. 

[I have almost since the beginning of my career as a laparotomist 
adopted the plan of compressing the pedicle by means of the clamp shown 
in the accompanying cut, which is merely an ordinary hemorrhoid clamp 
with a protecting surface of hard rubber ; cutting off the tumor, then 
ligating the pedicle in the double manner just described, and then searing 
off the portion of the pedicle situated above the clamp with the Paquelin 
thermo-cautery at red heat. My object in doing this is partly to guard 
against any possible secondary hemorrhage, which I really do not believe 
could occur if the ligature is properly tied, and partly to prevent adhesion 
of the fresh pedicle to neighboring organs. After removal of the clamp 
and inspection of the pedicle to see that it is thoroughly seared, the ligature 
is cut short and the pedicle dropped. I have never had occasion to deplore 
using this double method, which first occurred to me after reading the 
splendid results achieved by Keith by means of the cautery alone. — 
P. F. M.] 

The division of the pedicle by the cautery only, although eminently 
successful in the hands of Dr. Thomas Keith of Edinburgh, who 
reports 70 successive ovariotomies treated in this way without a death, 
has still not seemed to us sufficiently secure to warrant our employing 
it. We have preferred, as stated, either to use the ligature alone or the 
ligature and cautery together. 

The dangers which may possibly ensue from the pedicle after ligation 
are the slipping of the ligature, with subsequent hemorrhage, and, if 
not detected and rapidly arrested, death ; gangrene of the stump, which 
we have stated does not occur, although theoretically it might be feared ; 
and finally the attachment of the stump to intestines or the neighbor- 
ing peritoneum. The latter accident undoubtedly occurs more fre- 
quently than is desirable, and the local pain so often complained of in 
the region of the pedicle after the removal of ovarian tumors or dis- 
eased ovaries and tubes is undoubtedly due to some such complication. 
Unfortunately, nothing can be done for it except the reopening of the 
abdominal cavity and the detachment of the adhesions. Occasionally 
even cysts of the broad ligament may be drawn out so far as to enable 
the operator to form a pedicle out of the combined layers of the broad 
ligament, but this is the exception, and enucleation of such cysts the 
rule. 

Before proceeding to the next step of the operation, the remaining 
ovary should always be carefully examined as to the existence of disease. 
During the removal of a large ovarian cyst it is very common to find very 
small cysts disseminated throughout the other ovary. If any of these 
have obtained considerable size, it is advisable that the organ should be 
removed. But if they be too small to call for this course, the matter 
may be compromised by puncturing them with a needle. Pippingskoeld l 
of llelsingfors, Finland, advises that the small cysts should be punc- 
1 Am. Journ. Obstetrics, April, 1880. 



734 OVARIOTOMY. 

tured and their walls rapidly but efficiently cauterized with a pointed 
actual cautery. He declares that he has resorted to this plan in many 
cases, and with uniformly good results. 

The late Prof. Schroeder was, we believe, the first to recommend 
and practise the conservative method in cases of small cysts of the 
second ovary. He excised the walls of the cyst, scraped its cavity 
gently with the curette, and united the edges of the cyst by fine inter- 
rupted catgut sutures, and returned the organ to the abdominal cavity. 
We have repeatedly adopted this procedure, and, while we have never 
had occasion to see the ovary thus treated again, have had no reason 
to regret its performance. Many an ovary can thus be saved which, on 
the general principle that a cystic ovary which is liable to become an 
ovarian tumor should always be removed, would have been sacrificed. 
The possibility of future impregnation is certainly preserved by this 
conservative treatment. 

Cleansing the Peritoneum. — The sac having been removed and hem- 
orrhage checked, all fluids contained in the peritoneal cavity should be 
carefully removed by soft sponges squeezed out of warm carbolized 
water. Not only the intestines and abdominal walls, but especially the 
pelvic cavity, should be completely and thoroughly cleansed. This is a 
point of great importance, and may decide the issue of the case. Every 
particle of fluid left may undergo decomposition, and expose to the 
great dangers of septicaemia and peritonitis. 

We have retained the above directions from our last edition, because 
they are substantially correct and should be followed as nearly as pos- 
sible in every case ; but with the careful antisepsis which is now carried 
out in every surgical case, and, as we have stated, particularly in ovari- 
otomies, it is of much less importance to remove every particle of cyst- 
fluid, blood, or serum from the abdominal cavity than was the case in 
former days. Our present rule is to sponge out the pelvic and abdom- 
inal cavity but very slightly and gently with sponges attached to 
holders. 

If we are in doubt as to whether any cyst-fluid, pus, or blood-coagula 
are still left in the abdominal cavity, we prefer to wash out the latter 
with warm boiled water at a temperature of 100°, or Thiersch's solu- 
tion at the same temperature, poured into the abdominal cavity from a 
pitcher until the fluid escapes entirely clean. The presence of a few 
fresh coagula or a slight amount of cyst-fluid, even when mixed with a 
few shreds of plastic lymph, appears to be of no special consequence, 
since we have closed many an abdominal incision under such circum- 
stances, and have never seen the slightest sign of septic infection or 
inflammatory reaction ensue. 

Establishing Drainage. — Definition. — Drainage means the intro- 
duction into the abdominal cavity after abdominal section of a tube 
or some other substance, by means of which a discharge of fluid 
from the cavity is rendered possible so long as the drain is left in 
place. 

Indication. — The indication for such drainage is either the prob- 
ability that a greater or lesser amount of bloody or serous secretion 
will take place within the peritoneal cavity after the operation, or that 



DRAINAGE. 735 

certain noxious substances, such as cyst-fluid, pus, or blood, have been 
unavoidably left in that cavity. A further indication might be the 
fear that a secondary hemorrhage might occur, the diagnosis of which 
would be facilitated by the presence of a drainage-tube. At present 
we usually prefer drainage through the abdominal incision. A few 
operators, chief among whom is Martin of Berlin, prefer the vaginal 
vault, and pass a rubber drainage-tube from Douglas's pouch into the 
vagina, mostly in cases of complete removal of the uterus and append- 
ages for fibroids. The late Dr. J. Marion Sims advocated vaginal 
drainage after the removal of ovarian tumors as a means of preventing 
septic infection through the accumulation of serum in Douglas's pouch. 
His theory, however, proved to be erroneous, since such an accumula- 
tion of serum in Douglas's pouch, if the operation has been performed 
with proper antisepsis, is of no consequence whatever. As nearly all 
his patients died upon whom this method was practised, it was soon 
abandoned. 

There is no one point in the operation of ovariotomy, or indeed in 
the whole domain of abdominal surgery, on which there is a greater 
diversity of opinion than upon the necessity, the indications for, and 
the utility of drainage. Nearly all operators agree that whenever there 
is the probability of any serous or bloody discharge after the operation, 
or when purulent cystic or hemorrhagic effusions have been accidentally 
left behind, a drainage-tube is indicated. This would apply chiefly to 
cases where large raw surfaces have been left in the abdominal cavity, 
as after the enucleation of adherent ovaries and tubes, the separation 
of numerous adhesions between an ovarian cyst and neighboring organs, 
the escape of pus into the abdominal cavity during the removal of an 
abscess of the ovary or tube, and when the cyst had ruptured before 
the operation and chronic peritonitis exists. The English and the 
majority of the American operators employ drainage in such cases, and 
follow the rule, "Whenever in doubt, drain." The German operators, 
on the other hand, have discarded drainage as much as possible, relying 
upon their thorough observation of antiseptic precautions, upon the 
careful cleansing and washing out of the abdominal cavity, and the 
perfect adaptation of the lips of the wound. They feel that with a 
perfectly clean, aseptic abdominal cavity a small effusion of serum or 
blood into it subsequent to the closure of the wound is of no conse- 
quence. [And I, for my part, feel disposed to agree with them. I 
read before the American Gynecological Society in 1887 (see Transac- 
tions for that year) a paper on " Drainage after Laparotomy," in which 
I advocated the avoidance of drainage whenever possible under the 
careful observance of the rules just stated as followed by the German 
surgeons, and I have since then had repeated opportunity to confirm 
my opinion there expressed. From my experience I am compelled to 
believe that a drainage-tube, when the abdominal cavity lias been care- 
fully cleansed and all possibility of secondary hemorrhage is excluded, 
is of no use whatever, and may be even a source of danger through the 
local irritation which it produces on the peritoneum and the adjacent 
intestines, through its interference with the proper peristaltic movements 
of the gut, ami through possible reflex gastric disturbance which I 

47 



736 OVARIOTOMY. 

think I have observed in two instances. While I would, therefore, not 
hesitate to employ a drainage-tube when absolutely forced to do so, I 
would always feel much safer as regards the recovery of my patient if 
I could conscientiously omit the drainage and close the abdominal 
incision. — P. F. M.] Bantock is one of the most active adherents of 
the drainage-tube, using it in probably four-fifths of his cases. Tait 
likewise very frequently employs it, and the results of both these gen- 
tlemen are so brilliant that it would almost seem a sacrilege to question 
the utility of the method. Still, Olshausen very seldom if ever uses 
drainage, and in the last edition of his book on the Diseases of the 
Ovaries says that since July, 1882, he has not drained in any case of 
completed or uncompleted ovariotomy, although* many complicated and 
unclean cases occurred to him in which frequently the condition of the 
patient prevented careful toilet of the peritoneum. His last two patients 
treated with drainage died of septicaemia. Since then, of 124 ovariot- 
omies, not one died of septic infection. Even in cases of enucleation 
of laro-e subserous and intraligamentous tumors, from the bed of which 
oozing is more than probable, Olshausen advises against drainage, pre- 
ferring to stop oozing by pressure, and after thoroughly cleansing the 
cavity by sponges dipped in carbolized water to leave it open and to 
completely close the abdominal wound. His objections to drainage are 
secondary septic infection, tedious suppuration, and an abdominal fistula 
which may persist for years. Dr. Groodell of Philadelphia is by no 
means a firm believer in the drainage-tube, but thinks it of value in 
detecting a possible secondary hemorrhage. Injections into the abdom- 
inal cavity through a drainage-tube should under no circumstances 
be employed; they are useless, unnecessary, and dangerous, because 
they are liable to break up fresh adhesions and thereby distribute 
possible septic matter through the, as yet, uninfected peritoneal 
cavity. 

Before closing the question as to the indications for abdominal 
drainage we wish to place ourselves on record as in favor of the method 
under certain rather rare circumstances, but as opposed to it whenever 
the probability is that there will be no discharge into the peritoneal 
cavity which would be productive of injury. With a few exceptions 
we have found that the amount of bloody serum withdrawn from the 
drainage-tube during the first twenty-four hours after the operation was 
so slight that we can hardly imagine that its retention would have pro- 
duced the slightest evil effects. Hence we could not but feel that the 
drainage-tube was entirely unnecessary. We must leave it to the indi- 
vidual judgment of each operator as to whether he thinks it best to 
emplo}^ drainage in any given case after he has considered the remarks 
made in the preceding lines. 

Method of Drainage. — The only two methods of drainage which we 
now employ are the following : 1st. By means of glass tubes of different 
sizes and lengths, slightly curved so as to conform to the posterior curve 
of the uterus. These are introduced, after the abdominal cavity has 
been cleansed by irrigation and careful sponging, into Douglas's pouch, 
and the lumen is filled by a loose plug of iodoform gauze. A tube of 
such length should be chosen that it touches the bottom of Douglas's 



METHOD OF DRAINAGE. 737 

pouch without protruding far above the abdominal skin. It is of 
course important that no injurious pressure should be exerted against 
Douglas's pouch. This tube is introduced just before the abdominal 
incision is closed and before the dressings are applied. Such fluid as 
may be present in the tube is soaked up by a syringe to which a long 
rubber tube is attached. We are in the habit of leaving two sutures 
free in the abdominal wail at the spot where the tube rests — that is, in 
the lower angle of the wound. These sutures are prevented from slip- 
ping by means of clamped shot at each end. Their object is to enable 
a rapid and complete closure of the entire depth of the abdominal wound 
when the tube is removed. In this way the formation of a sinus and 
possible subsequent ventral hernia is thought to be to some extent pre- 
vented. Every three hours, at the longest, after the patient has been 
returned to her bed the packing of the tube is removed, and such fluid 
as may be contained in it drawn up with the syringe. As soon as this 
fluid loses its clear bloody character and becomes serous and diminishes 
in quantity down to from one to two drachms, which in our experience 
usually takes place within twenty-four hours after the operation, the 
tube should be removed and the wound closed by the sutures left ready 
for that purpose. We can remember but two or three instances in 
which so much discharge of bloody serum took place after an ovari- 
otomy, with many flat adhesions which could not be ligated, that we 
could see the real utility of the drainage-tube. In by far the majority 
of cases in which it was used the amount of bloody serum secreted 
within twenty-four hours was so slight that we do not believe it would 
have in any way injured the woman if it had been allowed to remain 
in the cavity of the peritoneum subject to the absorbent powers of that 
membrane. 

Double drainage-tubes made of glass or hard rubber, which have 
been introduced both by Thomas and by H. Marion Sims with the 
object of pouring a steady stream of water through the tube, and thus 
washing and thoroughly irrigating the abdominal cavity, have, we 
think, now been almost entirely discarded, for the simple reason that 
they have been found unnecessary and are too complicated for complete 
cleanliness. 

2d. Iodoform gauze has been recommended as a means of drainage, 
chiefly by Mikulicz of Vienna, who packed large bleeding or absorbing 
cavities in the abdomen with it and carried the end out of the abdom- 
inal wound. The gauze thus applied acted both as a hemostatic and a 
capillary drain. Its deodorant quality prevented it from becoming 
offensive, and it could thus be left in place for a period varying from 
three days to a week, when it was gently withdrawn, and if necessary 
replaced by a new packing. The results obtained by this method of 
hemostasis and drainage in cases of intraligamentous cysts and rup- 
tured pelvic hematomas have been simply marvellous. 

Dangers. — We have already referred to the dangers which may 
result from the practice of drainage, and will merely recapitulate that 
peritoneal irritation, interference with the peristaltic action of the intes- 
tines, and therefore free evacuation of the bowels, reflex gastric disturb- 
ance, and Anally the introduction of septic infection, are the chief objee- 



738 



OVARIOTOMY. 



tions to the use of the drainage-tube. 
Fig. 316. 




Some operators employ drainage- 
tubes with numerous small 
the shaft of the 



openings in 



and these 



generally 



tube, 

have complained of incarce- 
ration of portions of omentum 
in these openings. For this 
reason we do not employ this 
form of drainage-tube. (See 
Fig. 316.) The length of 
time which a drainage-tube 
should be left in the abdom- 
inal cavity depends entirely 
amount and character of the secretion drawn from the tube 



Drainage-Tubes. 



upon the 

at the given intervals 



We have seldom found it necessarv to leave a 



drainage-tube more than forty-eight hours ; recently, indeed, twenty- 
four hours has usually satisfied us that the drainage-tube had fulfilled 
its purpose. In former times the tube was often left in one, two, and 
even four weeks, but we have seen very few such cases. 

Closing the Wound. — The pedicle having been dropped, the peri- 
toneal cavity thoroughly cleansed by very gentle sponging, and, if 
thought necessary, by irrigation with boiled water or Thiersch's solu- 
tion, the next step is to close the abdominal incision. The sutures 
employed for this purpose may be either silver wire, silk, silkworm 
gut, or catgut. Some operators employ silver wire exclusively, others 
silk and silkworm gut for the deep sutures and catgut for the peri- 
toneum and successive layers of fascia, and others again use catgut 
entirely. The latter are probably in the minority. We have employed 
silver wire extensively, and think highly of it. We also believe that 
silk is an excellent suture, and, if properly prepared, open to no objec- 
tions ; but of recent years we have preferred the silkworm gut because 
it is finer, makes a smaller stitch-hole, and is less liable to cause abscess 
in the abdominal walls ; and our practice is, if the incision is short, to 
use only sutures which enclose the entire abdominal wall on either side, 
inserting them at the upper part of the left side of the wound, passing 
them entirely through the abdominal wall, including the peritoneum, 
and reinserting them at the corresponding point on the other side. 



the 



incision 



is long and the abdominal Avails much relaxed, we first 



insert the deep sutures as already described ; all of these being in posi- 
tion, we secure their ends by artery-forceps to prevent their being acci- 
dentally withdrawn, and then sew the peritoneum together by a running 
and interlooped catgut suture. Sometimes we have thought it well to 
tie this suture in tiers upward until the subcutaneous fat was reached. 
The objection to this procedure is the prolongation of the operation. 
Finally, the abdominal stitches are securely tied. During this whole 
procedure the wound is kept bathed in a 1 : 3000 solution of bichloride ; 
that is to say, after the peritoneal cavity has been closed, for we need 
hardly remark that no bichloride solution, no matter how weak, is 
allowed to enter the peritoneal cavity. There are different methods of 
closing the abdominal wound, peculiar to as many diiferent operators. 




A VTER- TEE A TMENT. 739 

We cannot, however, enter into the details of these methods, believing 

7 7 7 O 

that the one which we have described answers every practical purpose. 
As many sutures should be introduced as are necessary to bring the 
edges of the wound into complete apposition ; if necessary, superficial 
stitches of catgut being added for this 

purpose. The needles which we use Fig. 317. 

are about three inches long, sharp 
pointed, and with cutting edges, 
curved nearly to a semicircle ; they 
are known as Schroeder's needles. 
We have found them the most con- 
venient for the abdominal suture. Of 

-p. , , . , , -,, 1. Needle for Vesicovaginal Fistula Ope- 

COUrse, reaslee S eye-pomted needle ration. 2. Needle for Primary Peri- 

~ \, ~™ 1^ ,~A -fu™ +U~ ™ neorrhaphy, or abdominal suture after 

may be employed tor the same pur- laparotomy, 
pose, and Hagedorn's needle, as well 

as others, will answer ; but we would advise in any case the employ- 
ment of a needle which is long, strong, and sharp enough to easily 
penetrate the abdominal wall, and allow of its being carried through 
even very rigid parietes without danger of its being broken. 

The last stitch having been introduced, all the sutures are carefully 
tied, and the abdominal wall is cleansed with a 1 : 3000 bichloride solu- 
tion and dried ; a strip of rubber protective is placed over the incision, 
over this a pad of iodoform gauze, over this another pad of bichloride 
gauze, then a layer of absorbent cotton. A covering of rubber tissue 
and a light binder are carefully adjusted with safety-pins, so as to be 
neither too tight nor so loose as to permit traction on the edges of the 
incision. If thought best, the dressing may be secured by broad strips 
of adhesive plaster. The patient is then washed, dried, and, when she 
has recovered from the effects of the anaesthetic, conveyed to her bed. 

After -Treatment. — One of the most essential features for the suc- 
cessful issue of the case is the attendance of a careful and sensible 
trained nurse, who is sufficiently intelligent to know when the directions 
given by the surgeon are to be continued or when they should be tem- 
porarily suspended until he himself can change them in accordance 
with the circumstances. We make this remark advisedly, because we 
have seen nurses who, the administration of cracked ice in small quan- 
tities having been ordered to allay nausea and vomiting, continued to 
give the ice ad libitum, although the patient persisted in vomiting the 
ice in the form of water as soon as time had been given for it to melt. 
Obviously, the continuance of the administration of ice as a check for 
the vomiting was an absurdity, since it failed to effect its purpose, and 
something else should have been substituted or the attendant at once 
summoned to the case. 

No greater change in the treatment of operations of this kind can 
possibly be imagined than has taken place during the last ten or fifteen 
years. Even at the time of the publication of the last edition of this 
work the routine treatment after an ovariotomy was to keep the patient 
under the influence of an opiate sufficient to relieve pain, with bowels 
constipated by the same means, for a week or longer, and in case oi' the 
symptoms of peritonitis supervening the administration of the opium 



740 



OVARIOTOMY. 



was to be increased. All this has now changed so completely that, 
instead of giving opium after an ovariotomy, it is the very last drug 
that we should now employ. We know of a case operated upon by 
a celebrated English surgeon where the fatal result from peritonitis was 
ascribed by the operator to one or two hypodermic injections of mor- 
phine given to the patient by his assistant and her husband, also a 
physician, she having been for some time addicted to the morphine 
habit. While this may be rather an extreme illustration, still, we are 
now so convinced that opium is not only unnecessary, but injurious, 
after an abdominal section that Ave administer it only under the strong- 

Fig. 318. 




Ovarian Tumor weighing 149 pounds, operated on by C. K. Briddon of New York. Death. i 

est possible pressure, when no other means will control the pain from 
which such patients occasionally, even at the present day, do suffer. 
Instead of keeping the bowels constipated, one of our first thoughts is 
within twenty-four to forty-eight hours to produce an alvine evacuation ; 
and we feel that when this has been accomplished the recovery of our 
patient is two-thirds assured. This change in our views is due chiefly 
to the teachings of Lawson Tait, who, however, was by no means the 
discoverer of this method, since Seyfert of Prague recommended it as 
long ago as 1859 in the incipient stages of puerperal septicaemia. The 
idea of thus early starting up the intestinal secretions was that by 
thus evacuating the bowels any tendency to septic infection would be 
averted. HoAvever this may be, it is undoubted, and at present a 
matter of every-day experience, that a rise of temperature with more 
or less tympanites, preceded or not by a chill, is immediately con- 
1 New York Medical Journal, Feb. 8, 1890. 



A FTER-TREA TMENT. 741 

trolled by one or more copious evacuations from the bowels, and we 
have seen many a case of apparently incipient peritonitis aborted in 
the same manner. 

To return to the regular after-treatment. The patient having been 
placed in her bed, which has been previously warmed, is left perfectly 
quiet until she has entirely recovered from the effects of the anaesthetic, 
being of course watched by the nurse and attendants. Should vomit- 
ing supervene, which is not at all uncommon as a result of the anaes- 
thetic, small pieces of cracked ice or tablets of oxalate of cerium, three 
grains each, every half hour, should be administered, and no food what- 
ever is given for twenty-four hours. Stimulants are to be administered 
only if the weak condition of the patient seems to warrant them, dry 
champagne, iced brandy or whiskey being those to be chosen. When 
the vomiting has ceased, which in favorable cases is usually to be 
expected within twenty-four hours, kumyss or matzoon may be given 
in tablespoonful doses every hour or two hours, according to the condi- 
tion of the patient's stomach, and this quantity is to be gradually 
increased day by day with the addition or substitution of milk, raw or 
boiled, and after the fourth or fifth day beef-tea in moderate quantities. 
If the patient can empty her bladder herself, she should be allowed to 
do so; if not, she should be catheterized every six hours, care being 
taken to avoid the introduction of vaginal secretion into the bladder, 
which might produce a catarrhal cystitis. The temperature is to be 
taken every three hours, usually in the axilla, or, if the patient's stom- 
ach is not irritable, in the mouth ; the pulse and respiration likewise ; 
and all to be recorded on a chart specially prepared for the purpose. 
So also about the amount of food taken, the action of the bladder and 
bowels, and other remarks to be recorded. Ordinarily, in cases that 
run the usual course, the temperature should not exceed at any time 99° 
to 100° F., nor the pulse 80 to 90, nor the respiration 18 to 24. Should 
the temperature run above 100°, and even touch 101°, and should in 
addition tympanites appear, the indication for the speedy administra- 
tion of laxatives is present. We are in the habit of giving one-tenth 
grain doses of calomel by the mouth in the shape of granules or tab- 
lets, one every half hour until from fifteen to twenty have been taken, 
and immediately after the last one we begin with the administration 
of Rochelle salts in teaspoonful doses, dissolved in two ounces of hot 
water, every half hour until from four to six have been given. If the 
patient should vomit either the calomel, wdiich is unlikely, or the salts, 
we wait a few hours and recommence the series. Usually this treat- 
ment will result in a series of fecal evacuations, with a complete subsi- 
dence of the tympanites and of the febrile symptoms. Should these 
laxatives prove ineffectual and the tympanites increase, the administra- 
tion of a high enema containing one ounce of castor oil, one-half ounce 
of turpentine, to one pint of peppermint-water, should be ordered : and 
if this prove ineffectual within two or three hours it may be repeated. 
with the addition of an infusion of ox-gall instead of the peppermint- 
water. It is seldom that more than the remedies just reeonunended is 
required for the production of as many alvine evacuations as is thought 
necessary. In favorable eases usually even calomel may be dispensed 



742 OVARIOTOMY. 

with, and the Rochelle salts alone will accomplish the object. After 
the bowels have been thoroughly evacuated they should be kept open 
once a day at least by means of enemata or mild doses of salts. The 
dressing need not be looked at during the first week, unless either pain 
or persistent elevation of temperature leads to the supposition that there 
may be something wrong with the stitches, possibly the formation of 
abscesses in the abdominal wall. In case the latter is apparent, some of 
the stitches may be removed ; usually they are not removed until after 
the end of the first week. The patient is allowed to turn on her side 
from the very beginning, aided of course by the nurse if necessary, and 
should be encouraged as much as possible at every visit. In addition 
to the use of laxatives and enemas to operate upon the bowels, persist- 
ent rise of temperature may call for other antipyretic measures, among 
which may be mentioned ten- to fifteen-grain doses of phenacetin or 
antipyrin, or five-grain doses of antifebrin, and the use of the ice-bag 
or ice-water coil on the abdomen. Indeed, we are in the habit of 
employing the ice-bag on the abdomen after the majority of our abdom- 
inal sections, not so much because we fear peritonitis, as because the 
patients seem to be more comfortable and to feel less pain when the ice- 
bag is employed. If the stomach should be very irritable, and, as is 
liable to be the case during the first few days after the operation, resist 
all medicinal efforts, even sinapisms over the hypogastrium, to quiet it, 
rectal medication may be necessary until the gastric irritation is relieved. 
Rectal alimentation should consist in the injection of beef extracts 
(Leube's or Rudisch's) in two-ounce doses every two to three hours, 
together with a certain amount of brandy or whiskey, one-half to one 
ounce if necessary. We have kept patients alive in this way, we are 
convinced, for at least a week until their stomachs were able to retain 
food. 

Occasionally, after a very severe operation, the pulse runs quite high 
for several days, up to 120-140 beats in a minute, but the temperature 
does not correspond ; and this difference should be a favorable symptom 
to us, because the rapid pulse in such cases is usually due to the anasmia 
or to the reaction from the shock of the operation. A high tempera- 
ture and a low pulse, however, is far more serious, since it usually indi- 
cates a low form of' septic peritonitis. The older books nearly all give 
charts indicating the temperature and pulse during the first week after 
an ovariotomy, just as though there was any regularity in either 
after that operation. We will but say that an ovariotomy progress- 
ing to easy and rapid recovery should nowadays have no rise of tem- 
perature or pulse whatever ; further, that any increase of pulse or 
temperature usually means something, the exact nature of which should 
be ascertained as rapidly and thoroughly as possible. The rise may 
mean septic infection, peritonitis, or it ma}^ mean merely some trifling 
mental excitement or physical disturbance, such as constipation or tym- 
panites. It is the place of the attending surgeon to inquire into and 
discover the cause of the elevation of pulse and temperature, and it 
will usually not be a difficult matter for the experienced practitioner to 
decide where the cause lies and what is the remedy. No precise chart, 
therefore, of either temperature or pulse can be given as indicative of 



EVILS AFTER THE OPERATION. 743 

one thing or another in the course of the after-treatment of an ovari- 
otomy. 

The stitches are usually removed, under proper antiseptic precautions, 
between the seventh and the tenth days. The patient may be allowed 
to sit up in bed about the fourteenth day, out of bed probably about 
the sixteenth, and may be discharged, if everything goes well and the 
wound is thoroughly healed, about the eighteenth to the twenty-first 
day. Some women have been thought well enough to be sent home as 
early as the fourteenth clay. The usual time is from three to four 
weeks. The abdominal walls should always be well supported, espe- 
cially after the woman is allowed to sit up or walk about, by a carefully 
adjusted supporter, which she should be informed it will be necessary 
for her to wear for at least one or two years— the longer, the longer 
the incision. 

Evils after the Operation. — The two great dangers to be feared after 
an ovariotomy are septicaemia and peritonitis. Undoubtedly the majority 
of cases that die at the present day in consequence of an abdominal 
section succumb to septicaemia. How such an infection occurs in view 
of the careful antisepsis which is or should be carried out with each such 
operation is a mystery, and still such cases do occur. In some way septic 
germs have crept into the abdominal cavity, and in course of time make 
their presence felt. With the exception of those cases where the rise of 
temperature and pulse is due to intestinal distension and to a reaction 
from the operation, we are safe to consider any rise of temperature after 
an ovariotomy to be due to septic peritonitis or infection, and our first move 
will be to combat the danger by producing a copious evacuation from the 
intestines, and by reducing the temperature by antipyretics such as already 
mentioned, and by the use of the ice-bag or ice-coil to the abdomen. In 
the last edition of this work the reduction of temperature in septicae- 
mia by means of ice-water applications, chiefly to be given on a cot 
prepared for that purpose — the so-called Kibbee cot, after its inven- 
tor — was highly recommended. We have since entirely abandoned this 
method, having found it altogether too severe and mostly unnecessary, 
since we found ourselves able in the first place to forestall the occur- 
rence of septic infection by the more careful employment of antiseptic 
measures, and in the second place to counteract it when it had actually 
occurred by the means described in this section. Briefly, the produc- 
tion of copious intestinal evacuations, the use of the cold-water coil or 
ice-bag to the abdomen, and the reduction as required of temperature 
by the medicinal antipyretics (antipyrin, antifebrin, phenacetin), will 
at the present day enable us to overcome any case of septicaemia after 
a laparotomy which is indeed amenable to treatment. In very rare 
instances, where retention of septic material in the peritoneal cavity 
appears to be the cause of the sepsis, the reopening of the wound, break- 
ing down adhesions, and thorough irrigation of the septic cavity is of 
course the only proper treatment. As regards the peritonitis, its pres- 
ence will be usually detected by the abdominal pain of which the 
patient complains and by the distension of the intestines. Contrary to 
the practice formerly advocated, of constipating by means of opium, 
which answered very well in cases of peritonitis independent of an 



744 OVARIOTOMY. 

operation, Ave now feel that the instigation of peristalsis, and therefore 
the prevention of intestinal adhesions, by means of early catharsis, in 
the manner already indicated, is one of our greatest safeguards against 
a fatal development of this disease. The ice-coil to the abdomen, pre- 
ceded perhaps by turpentine stupes, the use of antipyretics, and, if 
necessary to relieve distension, the turpentine, ox-gall, and peppermint- 
water enemata already described, are among our most valuable reme- 
dies for this disease. In our experience a case of peritonitis after ova- 
riotomy seldom runs a long course ; it is either terminated speedily by 
a favorable issue or it runs to an equally rapid fatal result. Peritonitis 
arising after the first four or five days is usually of a septic character, 
and the question then arises whether it is not a good plan to reopen 
the cavity, separate adhesions, evacuate the septic fluids if they are 
found, and thus remove the cause of the sepsis. This is- still more or 
less an open question, and must be decided on the merits of each 
individual case. 

As a rule, our ovariotomies are either convalescent by the fifth or 
sixth day, and practically beyond danger, or they present complications 
which necessitate some subsequent operation, such as the opening of 
sinuses or the removal of ligatures which are endeavoring to force their 
way to the surface. It is very rare at present for us to meet with a 
case of ovariotomy in which the question of perfect recovery is left 
unsettled beyond the end of the first week. 

Irremovable Cysts. — Occasionally an ovarian cyst is found to be so 
firmly adherent to the walls of the pelvic cavity, to the intestines, and 
parietal peritoneum that its complete or even partial removal proves to 
be absolutely impossible, for to attempt to peel out such a tumor would 
inevitably result in the production of hemorrhage so profuse that it 
could not be arrested by any means at our immediate disposal, or by 
injury of vital organs, such as intestines, wmich we would be unable to 
repair. We have already cautioned against the possibility of mistaking 
the parietal peritoneum for the adherent wall of such a cyst. Usually 
the abdominal incision will find the walls of the belly oeclematous, 
thickened, and more dense than is natural, and on seeking to open what 
appears to be the thickened peritoneum the cyst-cavity will be entered. 
Our practice is in such cases, after emptying the contents of the cyst, 
if necessary, with aid of the fingers, to sew the cyst-wall and the 
abdominal walls together by means of interrupted catgut sutures, and 
after a thorough irrigation of the cyst-cavity to pack it fairly tightly 
with iodoform gauze, which can be left in for several days or even a 
week if no rise of temperature supervenes. The patient is otherwise 
treated precisely as after an ordinary ovariotomy. After removal of 
the gauze the cavity is irrigated with Thiersch's solution and repacked ; 
and this treatment is repeated every four or five days until gradually 
the cyst-cavity shrinks and fills up by granulations, so as to eventually 
become obliterated. This process may occupy several weeks, indeed 
several months, but the usual result of these operations is an ultimate 
complete recovery. A few operators have advised opening and evacua- 
ting the sac, then forcing a dressing-forceps carrying a large rubber 
drainage-tube through the bottom of the cyst into the vagina, and then 



INTRALIGAMENTOUS CYSTS. 745 

closing the abdominal wound. Drainage is then carried out through 
this vaginal tube and the cyst irrigated as often as may seem necessary. 
The result, of course, should be a gradual contraction and obliteration 
of the sac. We do not feel disposed to recommend this latter plan, 
having been uniformly successful with the abdominal method. 

Occasionally we have first aspirated such adherent cysts through 
the vagina under proper antiseptic precautions, and after ascertaining 
by examination of the fluid .that the cyst was ovarian, we have punc- 
tured the cyst with blunt-pointed scissors, enlarged the incision with 
a dilator, evacuated the contents, irrigated, and drained. Some of our 
cases treated in this manner have resulted successfully ; others, again, 
have continued to secrete for an indefinite period, and in one case of intra- 
ligamentous cyst recently met with an unexpected secondary hemorrhage 
took place during the night, undoubtedly from rupture of one of the 
large blood-vessels in the wall of the cyst, and the patient succumbed 
before the hemorrhage could be arrested [P. F. M.]. 

Intraligamentous Cysts. — Definition. — An intraligamentous 
ovarian cyst is one in which the tumor, instead of developing toward 
the abdominal cavity, grows inward and downward between the layers 
of the broad ligament, which it pushes before it anteriorly, posteriorly, 
and laterally, until it occupies a part or the whole of the pelvic cavity 
and encroaches upon the abdominal cavity, precisely as does an ordinary 
ovarian cyst. Still, as a rule, these intraligamentous tumors do not 
grow upward as freely and as rapidly as pediculated ovarian cysts, but 
are distinguishable by their firm and deep situation in the pelvic cavity 
and by their entire absence of mobility. 

Diagnosis. — The diagnosis is made by the signs just pointed out; 
that is, by the deep situation and immobility of the cyst in the pelvic 
cavity, by the pushing of the uterus to the opposite side and forward, 
and by the comparatively slight enlargement of the abdomen. Dia- 
gnostic aspiration made through the vagina reveals under the microscope 
the characteristic granular corpuscle of Drysdale, showing the cyst to 
be ovarian and not of the parovarium or a serous effusion between 
the layers of the broad ligament. 

Significance. — In our opinion these intraligamentous cysts of the 
ovary are the most difficult to handle — that is, to extirpate successfully 
— of any tumors of the ovary which it has been our fortune to meet. 
The reason for this statement is that such a cyst possesses no pedicle, 
and therefore, in order to remove it, must be shelled out or enucleated 
from its bed between the layers of the broad ligament. This in itself 
is a difficult piece of work, involving danger of rupture of the envelop- 
ing peritoneum and of blood-vessels which may produce severe hem- 
orrhage. Besides, after the enucleation of the sac, supposing it to 
have been successful, a large bleeding, freely-absorbing cavity is left 
behind which requires a long time to close, during which process the 
danger of septicaemia is never absent. The greatest danger in our 
mind results from the breaking down of the enveloping peritoneum 
during the enucleation of the sac. A ragged, bleeding, and freely 
absorbing cavity is then of necessity left behind, and remains a source 
of danger, and not infrequently of death. It is but seldom that a 



7-16 OVARIOTOMY. 

small intraligamentous cyst of the ovary can be lifted out of the 
abdominal incision, together with its enveloping folds of broad lig- 
ament, so as to enable the operator to form a pedicle, ligate, and 
remove the cyst with its peritoneal covering entire. 

Treatment. — After opening the abdominal cavity, instead of the 
smooth, glistening, pearly-white, or mottled surface of a pediculated 
ovarian tumor, we find a red, very vascular membrane presenting, and 
on introducing the fingers it is found that this membrane extends over 
to the pelvic wall on the respective side and to the fundus uteri on the 
other. There is no pedicle to be found, and it is evident that the tumor 
is one developed between the layers of the broad ligament. We can 
now either close the abdominal wound and open this cyst per vaginam, 
as already described in the preceding section on irremovable cysts, or 
we can seize the sac with vulsella forceps, draw it up as much as possi- 
ble into the wound, incise it so as to avoid injuring prominent blood- 
vessels, and, having evacuated its contents by means of the trocar and 
the fingers in the usual way, draw it up still more and endeavor to 
enucleate the cyst. If this is successful, the walls of the sac enclosing 
the cyst — that is, the folds of the broad ligament — are stitched to the 
edges of the abdominal incision by interrupted sutures passed entirely 
through the abdominal wall and the sac. The peritoneal cavity is thus 
entirely shut off from communication with the abdominal incision and the 
cavity situated between the layers of the broad ligament. If the whole 
of the cyst cannot be thus enucleated, as much as possible should be de- 
tached, removed, and the walls of what remains stitched to the abdominal 
wound as already described. A large cyst can in this way be very much 
diminished in size, and the cavity left to be filled up reduced to quite a 
small dimension. Having stitched the walls of the sac to the abdominal 
incision, the sac is irrigated with Thiersch's solution and packed with 
iodoform gauze, the subsequent treatment being precisely like that de- 
scribed in the previous section. We have had many excellent results 
from this plan of treatment, but we have been unfortunate enough to lose 
a number of cases from septic peritonitis and intestinal obstruction, in 
which the broad ligament had become so thin and friable that it was torn 
during attempted enucleation, and the removal of the ovarian cyst was 
found to be impossible. In such cases it was of course impracticable 
to stitch the torn edges of the broad ligament to the abdominal wound, 
and thereby close off the sac from the peritoneal cavity, and thus oppor- 
tunity was given for septic infection of the latter and intestinal adhe- 
sion, which brought about the fatal result. 

Solid Tumors. — The removal of solid tumors of the ovaries differs 
in no way from that of fluid or mixed cysts, except that the incision 
will have to be made of sufficient length to enable the operator to 
remove the tumor through it. The length of this incision will of course 
depend entirely upon the size of the tumor. The pedicle is usually 
thin and easily ligated and dropped. In cancerous tumors of the ovary 
the precaution should be taken to apply the ligature so far away from 
the tumor that it will lie in healthy tissue, since if the pedicle has already 
become diseased the ligature is very liable to cut and immediate or sec- 
ondary hemorrhage to result, which will probably prove fatal unless soon 



OOPHORECTOMY. 747 

discovered. The chances of recovery after the removal of cancerous 
tumors of the ovary will depend wholly upon the possibility of the 
entire removal of the malignant growth. If it has once spread by 
metastasis to the peritoneum or intestines, the operation may indeed 
prove successful, but the disease will inevitably return. 



CHAPTER XLV. 

OOPHORECTOMY. 

Definition. — Oophorectomy means the removal of the apparently 
normal ovaries ; that is, of ovaries which, so far as previous touch or 
macroscopical examination after their removal shows, are perfectly 
healthy. This operation has also been called normal ovariotomy — 
a term which is no longer employed : castration is the medical, spaying 
the popular, term for this operation. We have said that the ovaries 
are apparently normal, because under the microscope minute histological 
changes are often found in these organs, such as hyperplasia and atrophy 
of the stroma, not uncommon results of chronic ovarian congestion or 
inflammation, which are not apparent to the naked eye, and which still 
have a decided influence upon the production of the symptoms (local 
pain and reflex neuroses) which call for the operation. 

History. — As the creation of the male eunuch by removal of the 
testicles has long been known as a procedure practised for other than 
scientific purposes, so probably has that of the female eunuch by 
removal of the ovaries. The former procedure was, however, very 
commonly put into practice ; the latter very rarely so. The former 
is substantiated by unquestionable evidence; the latter rests merely 
upon vague tradition, which asserts that a king of Lydia had it prac- 
tised upon a lewd daughter, and that in India female eunuchs were 
thus created in the olden time. In the seventeenth century an Hun- 
garian swineherd is said to have castrated his daughter for the same 
reason as the Lydian king. 

In the lower orders of animals spaying has long been very exten- 
sively practised, and is so to-day. 

In 1823, James Blundell of London formally suggested the practice 
of this operation in a paper presented to the Royal Society of Medicine 
and Surgery of London. In this he suggested that the extirpation of 
the healthy ovaries would probably prove remedial for severe dysmen- 
orrhoea and for the menorrhagia which accompanies inversion of the 
uterus, where amputation is not practicable. 

On Aug. 17, 1872, Dr. Robert Battey of Georgia performed the 
operation for the removal of the healthy ovaries for the premature 
production of the menopause. Battey 's indication for the operation 
was dysmenorrhea of so severe a type that it rendered the life oi' the 
patient unendurable, influenced her general health, and had proved 
incurable by all other remedies. Hegar of Freiburg, in Baden, per- 
formed the same operation for the same object on July 27, 1872, but. the 



748 OOPHORECTOMY. 

patient dying, failed to publish his experience. Hence this operation for 
this particular purpose has been, and is still, called " Battey's operation." 
In the month of January, 1876, Trenholrne of Montreal performed 
the same operation, also for the purpose of bringing on the change 
of life, but not to relieve dysmenorrhoea, his purpose being to stop 
the bleeding and the growth of a uterine fibroid. In August of the 
same year Hegar independently performed the same operation, and he 
has since done so much to popularize this method of checking other- 
wise uncontrollable hemorrhage from uterine fibroids that the operation 
for the removal of the normal ovaries for this purpose has become 
known as " Hegar's operation." Lawson Tait claims to have performed 
the same operation for the same purpose in August, 1872, but he failed 
to publish his case until after Hegar's report, and hence his claim 
cannot be officially recognized. 

Theory of the Operation — Dr. Battey, basing his reasoning upon 
the fact that ovulation is the cause of menstruation, with all its accom- 
panying pelvic engorgement and nervous exaltation, drew the deduction 
that extirpation of the ovaries by putting a stop to ovulation would 
check its consequence, menstruation, and that thus many evils depend- 
ent upon these two processes would by it be cured. Such was his con- 
clusion, and to test the question he began practising the procedure. 
Very soon he was followed by others. 

Since then men of the highest reputation and greatest experience 
have from time to time published the results obtained by them from this 
operation, and expressed their opinions regarding its justifiability and 
indications. The late Prof. Schroeder was one of those who gave this 
operation for the indications first suggested by Battey a most thorough 
trial, and reported shortly before his death in 1887 a series of 10 cases 
of reflex mental and nervous disturbances supposed to depend upon the 
disordered functions of menstruation and ovulation. 1 His recital is 
most graphic and of exceeding interest and importance, and his results 
are instructive and to our minds quite conclusive. Out of the 10 cases 
operated by him, in only 4 was a recovery achieved which bade fair to 
be permanent. In the 6 others no or only temporary improvement 
resulted, and in several of these the condition even became worse. 
The operation cannot be said to be popular at the present day, and 
is justifiable only in extreme cases after exhaustion of all other known 
remedies and when sanctioned by consultation with other prominent 
gynecologists and neurologists. 

The removal of the ovaries for' the production of the premature 
menopause in cases of bleeding fibroids is, however, quite another 
matter, and stands upon an entirely different and more stable basis. 
Our experience is that in such cases oophorectomy not only checks 
the bleeding almost immediately in a large proportion of cases, but 
frequently also is followed by a diminution, and even entire absorp- 
tion, of the fibroid. Of course there are a certain number of failures, 
but generally the operation is successful. 

Results. — These should be divided into immediate and remote. 
The immediate results from removal of the ovaries other than for cystic 

1 " Die Castration bei Neurosen," Zeitschr.f. Geb. u. Gyn., xiii. 2, 1886. 



INDICATIONS. 749 

disease are exceedingly favorable ; indeed, one would scarcely expect 
a woman to die after the ablation of the apparently normal ovaries. 
The remote results, however, leave very much to be wished for. This 
remark applies almost entirely to the operation when performed for 
the relief of reflex mental and nervous disturbances. Local pain, 
such as dysmenorrhea or that accompanying chronic oophoritis, will 
of course be relieved, but hystero-epilepsy, insanity occurring at times, 
convulsions, hystero-neuroses other than epilepsy, are by no means 
relieved with a certainty or permanency which one could desire, and 
which would justify the frequent performance of this operation. If 
the local pain is due to adhesions of the ovary, the detachment and 
removal of the organ will probably result in complete relief; but we 
must warn most emphatically against the indiscriminate and hasty 
removal of ovaries for reflex nervous and mental troubles the exact 
relation between which and the ovarian functions cannot clearly be 
established. While the majority of women do recover from simple 
oophorectomy, this operation must still not be considered as either an 
entirely safe or a trifling one, since some do die, and in any case the 
removal of organs of such vital importance to a woman as are the 
ovaries should be well considered before it is practised. We do not 
look upon this question from the sentimental standpoint, and consider 
the operation immoral, or believe that it unsexes a woman, as has been 
stated, because we think that if the suffering complained of is to be 
relieved only by this operation, its performance is certainly justifiable ; 
and in our opinion a woman is not unsexed or deprived of her womanly 
feelings, or even sexual instinct, by the removal of the ovaries. Indeed, 
we have seen one instance in which, after the removal of the ovaries for 
a bleeding fibroid in a single woman of thirty-seven marriage took place, 
and extreme gratification during the sexual act was acknowledged by the 
patient [P. F. M.] ; and in no instance have we seen a woman changed 
physically or mentally from the normal condition after this operation. 

To enumerate all the operators and the operations of this kind which 
they have performed would now be too great a task, since the number 
of both is too large, nor could we learn from such a table how the ope- 
ration is viewed by different operators, since we believe that the removal 
of the normal ovaries for reflex neuroses has greatly diminished during 
recent years, although at first it was enthusiastically received throughout 
the world. Battey's operation, therefore, may be said to be on the 
wane, while Hegar's operation, on the other hand, holds its own. In 
this respect no change has taken place during the last ten years, and 
the opinion expressed by Munde in 1878 (see American Journal of 
Obstetrics^ vol. xi., 1878), " If the positive benefits of the operation 
were as assured as its rate of recovery, the opposition to it would soon 
cease," remains as true now as it was then. 

Indications. — Ovarian extirpation is recommended for the following 
conditions : 

Severe dysmenorrhea ; 

Excessive menorrhao-ia ; 

Insanity occurring at times of ovulation ; 

Hystero-epilepsy ; 



750 OOPHORECTOMY. 

Excessive hemorrhage with uterine tumors ; 

Hystero-neuroses, other than epilepsy of severe character ; 

Chronic oophoritis with severe symptoms ; 

Absence of vagina or uterus, the ovaries being present. 
Of course the surgeon would have to decide according to his judg- 
ment and his conscience whether the evils for which he proposed 
operating were of so grave a character as to warrant his exposing 
his patient to a procedure of the gravity which the sequel will prove 
this to be. 

The difficulties, the dangers, and the doubtful results of Battey's 
operation render it one to be avoided until all other resources have been 
tried, but when these have been exhausted, and death, or, what is often- 
times worse, a life of suffering, becomes the certain fate of the patient, 
it offers itself as a resource of great value. 

Methods of Operating. — The ovaries may be extirpated, either by 
cutting through the vagina into the peritoneal cavity, elytrotomy ; or 
by cutting through the abdominal walls, laparotomy. The statistical 
evidence is somewhat in favor of the former of these, but the difficulties, 
the uncertainty of success, and the possibility of cutting into the rectum 
make the latter decidedly preferable, except in certain exceptional cases 
which will soon be mentioned. In a number of cases, even after ely- 
trotomy, it has been found impossible to remove the ovaries, which 
were hidden away under masses of effused lymph, and as a secondary 
procedure laparotomy has been resorted to. 

The removal of the ovaries through the vagina has at the present 
day been practically abandoned, although in many instances, where the 
organs can be plainly felt through the vagina and are not adherent, the 
operation would be an exceedingly easy and safe one; but the majority 
of operators have united in adhering to the abdominal section, which 
they find quite as easy and safe, and less liable to be disturbed by pos- 
sible complications than, the vaginal operation. There is no particular 
difference in the technique of this operation from that described under 
Ovariotomy, except that we consider the opening of the abdominal 
cavity more difficult in this case on account of the non-distension of its 
walls, of the greater rigidity of the muscles, the usually greater amount 
of adipose tissue, and the danger of wounding omentum or intestine in 
nicking the peritoneal membrane. It should be stated that the tubes 
are always removed together with the ovaries in this operation. For- 
merly, we believe, this was not considered essential, and was not always 
done, but at present we think the removal of the tubes, which are 
assumed to be as healthy as the ovaries, to be an indispensable part 
of the operation. It is not because we hold, with Lawson Tait, that 
the tubes are, in part, the seat and origin of the menstrual flow, and 
that their being left behind would result in a persistence of that flow, 
but because their removal together with the ovaries is equally easy, and 
indeed a pedicle can be more easily formed if both organs are removed 
together. Besides, in the absence of the ovaries the tubes are of no 
possible use, and may even, if they remain permeable, give rise to sub- 
sequent trouble. The removal of loose, non-adherent ovaries and tubes 
is one of the easiest operations ; the pedicle is readily transfixed, tied,. 



DISEASES OF THE FALLOPIAN TUBES. 751 

and dropped, and the abdominal wound closed ; the whole operation 
occupying not more than ten or fifteen minutes, and, as already stated, 
recovery should be almost uniform. We need not say that all antisep- 
tic and other precautions enumerated under Ovariotomy should be 
observed and carefully carried out precisely as for that operation. 

Persistence of Menstruation after Removal of the Ovaries and Tubes. 
— Although usually the extirpation of the normal ovaries and tubes 
should effect the complete cessation of the menstrual flow, such occa- 
sionally is not the case, and every operator of extensive experience has 
met with a number of cases in which menstruation reappeared after this 
operation at more or less regular intervals for a certain length of time. 
In our experience this has been the case in about 4 per cent, of our 
cases. When the ovaries and tubes were diseased (not enlarged to 
tumors) and adherent, the persistence of a bloody discharge from the 
uterus at regular intervals has been even more frequently met with. 
How to explain the recurrence of menstruation after removal of both 
ovaries and tubes is not quite easy, and there are different opinions on 
this subject; some believing that it is merely the persistence of the 
natural habit ; others, that a portion of the ovary was left behind ; and 
others, again, that a third ovary exists. Each of these explanations 
may account for a certain number of cases. It is well to acquaint our 
patients with the possibility of this occurrence in order that they may 
not be disappointed or surprised, and imagine the operation a failure, 
and we should also inform our patients that an immediate cessation of 
the pain or reflex symptoms for which the operation was performed must 
not always be expected, and that some months may elapse before decided 
beneficial results may be experienced ; and they should also be prepared 
for the inevitable discomforts of a mental, neurotic, and physical cha- 
racter which accompany the establishment of the menopause, and are 
liable to extend over a number of months or even one or two years. 



CHAPTER XLVI. 

DISEASES OF THE FALLOPIAN TUBES. 

Anatomy. — The identity of structure of the Fallopian tubes and 
uterus will be appreciated by the study of the formation of these organs 
in the embryo, as described by recent observers, more especially by 
Leukart, Thiersch, and Kolliker. 

In the walls of the Wolffian body, situated near the kidneys, on 
each side, in the female embryo, a narrow canal develops which ends 
below in the two horns of the uterus, while the distal extremity per- 
forms " a movement of rotation from before backward and from above 
downward ; the whole, together with the ligaments of the ovaries and 
the round ligaments, being enveloped in double folds of the peritoneum, 
which enlarge with the growth of the parts themselves, and constitute 

48 



752 DISEASES OF THE FALLOPIAN TUBES. 

finally the broad ligaments of the uterus." 1 Coming together at the 
median line, these canals coalesce or undergo fusion, forming the lower 
portion of the uterus and the entire vagina down to the hymen. The 
fundal arch is now formed, in all probability from fusion progressing 
from below upward, although this is somewhat doubtful. Thiersch 2 
thinks from observation on the embryos of sheep that it occurs from 
below upward ; while Kolliker, who experimented on those of cattle, 
believes that it occurs from the centre. Prof. Dohrn, who experimented 
upon embryonic foxes, sheep, pigs, and cattle, concludes that it begins 
between the middle and lower third, and extends upward and down- 
ward. All this occurs very early in embryonic life ; according to 
Dohrn, it is completed by the end of the second month. From the fact 
of this identity of structure there naturally exists between these organs 
a close sympathy in health and disease. 

In the adult woman, according to Carl Hennig, 3 the right tube is 
nine and a half centimetres (three and three-fourths inches), while the 
left measures only eight and a half. The abdominal extremity has 
attached to it five large and ten small fimbriae. The walls of these 
tubes consist — 1st. Of peritoneum, Avhich covers them to the fimbriated 
extremities ; 2d. Of connective tissue, in which are interspersed two 
sets of muscular fibres, external or longitudinal and internal or trans- 
verse, which are continuations of the muscular tissue of the uterus and 
broad ligaments. At the point where these tubes enter the uterus Hen- 
nig declares that the longitudinal and transverse layers of fibres both 
become greatly developed, and that the latter forms here a distinct 
sphincter tubce. 3d. We find within and lining the tube a mucous 
membrane, which is thrown into large and small folds, which are very 
evident near the fimbriated extremity, and gradually become insignif- 
icant as we advance toward the uterus. Within this membrane Mr. 
Bowman discovered tubal glands, which consist of grape-like structures, 
extending downward toward the subjacent muscular fibre. They differ 
from the muciparous follicles of the vagina, the Nabothian glands of 
the cervix, and from the utricular follicles of the uterine cavity. Kol- 
liker denies the existence of these, but Hennig 4 describes them very 
fully. These compound glands of the Fallopian tubes are lined with 
an epithelium of basement form. The mucous membrane covering- 
over the tubes, and not dipping down into these glands, is covered by 
a ciliated epithelium, the broom-like action of which is exerted toward 
the uterus. The object of this seems to be to sweep the products of 
the ovaries into the uterus, and to force in the same direction menstrual 
blood oozing into the tubes from their mucous lining, as a result of 
ovulation. The zoosperms, which are known to pass through the uterus 
and proceed as far as the ovaries, are themselves endowed with power- 
ful ciliary action in the single cilia which each possesses, and by this 
they overcome the opposing force of the tubal cilise. 

1 Treatise on Human Physiology, by J. C. Dalton, p. 645. 

2 Prof. Dohrn of Marburg, " Transac. Insbruck Convention," Amer. Journ, Obst., 
vol. iii. p. 167. 

3 Uterine Catarrh, translation in Am. Journ. Obst., vol. iii. p. 468. 

4 Loc. cit., p. 473. 



SALPINGITIS. 753 

It is highly probable, to say the least, that the erectile condition 
induced in the mucous membrane of the uterus and tubes by contrac- 
tion of the middle coat of their muscular fibres produces in the latter, 
as in the former, rupture of blood-vessels and consequent hemorrhage. 
Hennig declares that "during 1 menstruation, throughout its entire sur- 
face, it (the mucous membrane of the tubes) assumes a dark-red color." 
Ruysch, an old anatomist of Amsterdam, who wrote in 1737, describes 
a post-mortem examination in which he discovered the Fallopian tubes 
containing blood. This has by some of the writers upon the history 
of hematocele been construed into a record of that affection, but the 
passage appears to refer merely to a condition which depends upon ovu- 
lation. Messrs. Bernutz and Goupil 2 mention instances of the collec- 
tion of blood in the Fallopian tubes in consequence of obstruction of 
these canals. Dr. Duncan 3 admits that some blood may come from the 
tubes in natural menstruation. Tait, Bandl, Johnstone, and other 
recent authors insist that blood exudes physiologically from the healthy 
tube during normal menstruation ; and we see no reason to doubt this 
occurrence. We have repeatedly found the tubes, in cases where we per- 
formed laparotomy near the menstrual period, in an intensely congested 
state, which was not due to catarrhal inflammation ; and twice Thomas 
saw menstrual blood discharged from the tube enclosed in a clamp after 
ovariotomy, the patient at the same time menstruating from the vagina. 

Malformations of the Tubes. — The tubes may be congenitally 
absent, as in absence of the uterus and ovaries, or they may be of 
unequal length, or the fimbriated extremity may be double, there being 
two ostia ; or there may be found one or more small cysts of the size 
of a pea or bean dependent from the fimbriae. These cysts are believed 
to be an elongation of Mliller's duct : they were first described by 
Morgagni, and are called " Morgagni's hydatid." They are found so 
often — that is, about once in every five cases — that they can scarcely be 
considered pathological. They have no special significance, except that 
they may become adherent to the intestine or neighboring peritoneum, 
and then cause distortion of the tube and possibly extra-uterine preg- 
nancy. Other distortions of the tubes are produced by inflammatory 
adhesions and constrictions, and will be considered in the next section. 

The diseases by which the Fallopian tubes may be affected are the 
following : 

Inflammation ; 
Stricture ; 
Distension ; 
Displacements. 

Tumors. 

Inflammation of the Tubes, or Catarrhal Salpingitis, con- 
sists in inflammation of their mucous membrane, and may be either 
acute or cl ironic. 

The acute variety generally results from puerperal endometritis, or 
from gonorrhoea, which has extended through the uterine mucous mem- 

1 Loc. cit., p. 470. > Op. cit.. vol. i. 

3 Fecundity, Fertility, and Sterility, p. 3S8. 



54 



DISEASES OF THE FALLOPIAN TUBES. 



brane. [I have twice seen this disease almost destroy life by attacking 
the uterine mucous membrane, and subsequently producing pelvic peri- 
tonitis, doubtless reaching the peritoneum by traversing the tubes. — 
T. G. T.l 

Fig. 319. 




Unusual Length of Tubes with Enlarged Ovaries (Beigel). 

• Dr. Noeggerath, then of New York, in 1876 astonished the medical 
w r orld by the publication of a work entitled Latent Gonorrhoea in the 
Female Sex, 1 which was published in the German language, but soon 
became widely known in every country. In this work he claimed that, 
as the result of personal experiences of many years in his own practice, 
one of the most common causes of female sterility was the production 
of inflammation of the Fallopian tube in consequence of uncured gonor- 
rhoea or gleet in the husband. He affirmed, indeed, that no well- 
marked case of gonorrhoea in the male was ever entirely cured, and 
that consequently infection of the female was a common result soon 

1 Die latente Gonorrhoe im weiblichen Geschlect, Bonn, 1876. 



IN FLA MM A TION. 7 5o 

after marriage. The poison of the uncured gonorrhoea or gleet was 
carried into the uterus with the semen, and thence to the mucous mem- 
brane of the tubes, there exciting catarrhal inflammation and suppura- 
tion, eventually discharge of pus into the peritoneal cavity, localized 
peritonitis, and adhesions sealing up the fimbriated extremity of the 
tube or attaching it to the ovary or the neighboring peritoneum. In 
this way both the ova and the spermatozoa would be prevented from 
entering the tube, since the uterine extremity of the tube also was often 
closed by adhesive inflammation. At first Noeggerath's views were 
received with a great deal of scepticism, and were admitted to be true 
only for a very limited number of cases ; 'but gradually they have 
gained ground, and undoubtedly are now correct in very many instances 
where formerly the disease was attributed to other causes. There can 
be no doubt, however, that he went entirely too far when he asserted 
that no case of gonorrhoea in the male was entirely cured, and always 
remained a source of danger to the woman with whom such a man had 
intercourse. If that were the case, probably but very few women who 
marry young men who have been more or less gay in their early lives 
would be free from pelvic disease or would have children ; and every 
one knows, perhaps more or less from personal experience, that this is 
not the case. Noeggerath's statements apply to a very large portion 
of the community, but still by far to the minority. 

We have no doubt that many cases of acute catarrhal salpingitis 
are due to the extension of a chronic endometritis to the tube, and per- 
haps even to some active cause, such as exposure to cold during men- 
struation, excessive venereal excitement, imprudence in exercise during 
very cold weather, such as skating, equestrianism, bowling, etc., fol- 
lowed perhaps by rest on the cold ground while overheated. We have 
seen a case of pyo-salpinx in a young girl of sixteen produced by expo- 
sure to cold after overheating during skating, and we have seen numer- 
ous cases of catarrhal salpingitis in young women whose intact hymens 
precluded the slightest possibility of venereal infection. — [P. F. M.] 
Chronic salpingitis may either follow the acute stage, or else it may be 
the result of a gradual and slow extension of a chronic endometritis ; 
while in the milder forms the tube retains its normal calibre, and the 
catarrhal inflammation shows itself only by an increase of hyperemia 
of all the tissues of the canal. If the disease lasts for a long period or 
is of a very aggravated type, gradually the other tissues of the tube 
besides the mucous membrane participate in the inflammatory process, 
and a hyperplasia of the muscles and areolar tissue takes place which 
results in an hypertrophy of the tube, which may then attain the diam- 
eter of the little finger or even larger, its walls being hard and tense 
and the calibre of the tube often diminished instead of increased. The 
secretion contained in such an hypertrophied tube is either mucus or 
serum and mucus, or perhaps a drop of thin pus ; but this is not pyo- 
salpinx, properly speaking, since there is no accumulation of pus or 
dilatation of the tube. Of course, if the fimbriated and uterine 
extremities of the tube become closed, gradually an accumulation of 
secretion may result in dilatation of the canal and the formation of a 
hydro- or pyo-salpinx. This condition of inflammatory hypertrophy 



756 



DISEASES OF THE FALLOPIAN TUBES. 



of all the tissues of the tube has been called independently by Munde 1 
and Kal ten bach 2 "pachysalpingitis," or inflammatory thickening of the 
tube. It is a very common disease, and met with in our experience 



Fig. 320. 




Fallopian Tubes, thickened, distorted, and adherent by local peritonitis (pachysalpingitis) 

(Munde). 

far more frequently than pyo-salpinx proper. An hypertrophied tube 
is usually distorted in shape and bound to the ovary and Douglass 
pouch by adhesions. 

The great danger in both acute and chronic salpingitis is pelvic 
peritonitis, which may spread and destroy life. This arises in part from 
escape of the contents of the inflamed tubes into the peritoneum. 

A general peritonitis from the escape of the contents of a tube 
which is in the condition of acute or chronic catarrhal inflammation 
is rarely met with. The inflammation of the peritoneum is generally 
confined to Douglas's pouch, and results in the formation of adhesions 
between the tube, ovary, and neighboring surface of peritoneum, chiefly 
the posterior layer of the broad ligament. These adhesions effectually 
seal off" the rest of the peritoneum from the inflammation, which there- 
fore does not spread, and hence seldom endangers life. It is only in 
consequence of a repetition of this inflammatory process, which may 
take place any number of times, that eventually local suppuration and 
consequences perhaps endangering life may set in. Constriction and 
closure of the tube are by far the most common results of salpingitis, 
but we are in doubt as to whether it ever occurs except in consequence 
of the retention of fluids in that canal, and before such retention can 
take place stricture of its two orifices must be present. 

Some authors have thought that they had succeeded in passing the 
uterine sound through the tube into the peritoneal cavity. Cases 
apparently proving this fact have been reported by Hildebrandt, Yeit, 
Matthews Duncan, Noeggerath, Thomas, and others. It is a question 
whether in those cases the sound really entered .the dilated tube, or 
whether the soft, pulpy fundus uteri was not perforated by the instru- 
ment. The latter accident has occurred so frequently (see chapter on 
the Uterine Sound) and in the most experienced hands that we cannot 
help believing that the cases of sounding of the tube referred to were 
really instances of perforation of the fundus. Strange to say, this latter 
accident usually entails no serious consequences. 

1 "Electricity as a Therapeutical Agent in Gynecology" Am. Journ. Obst., 1885, 
p. 1256. 2 Centralblfiir Gyn., No. 43, Oct. 24, 1885. 



SYMPTOMS. 757 

Symptoms. — The signs of an acute salpingitis are very similar to 
those of a localized acute pelvic peritonitis — namely, sharp pain in one 
side of the pelvis or the other (usually in both, since, Ave may add, this 
affection is more likely to be bilateral than confined to one side only), 
moderate rise of temperature and pulse, and considerable constitutional 
disturbance. An examination reveals merely a greater amount of 
tenderness in one or both ovarian regions ; perhaps, if the examiner 
is very expert or unusually fortunate, the detection of the swollen tube. 
One of the most common symptoms of the chronic form of catarrhal 
salpingitis is the recurrence of painful menstruation, so-called menstrual 
colic ; which attacks are often very similar to those of chronic peri- 
tonitis of a mild type. In prostitutes this menstrual colic is due usually 
to salpingitis, and many young married women undoubtedly acquire the 
disease from excessive sexual indulgence during the honeymoon. A 
leucorrhoeal discharge, usually of a sero-purulent character, is present 
in such cases, sometimes coming on in gushes, as though there were a 
discharge of accumulated secretion from the uterus or the tube. 

The diagnosis is usually made by these symptoms and by the 
exclusion of inflammation of the ovary, which can be felt as neither 
enlarged nor particularly tender, and of an intra-peritoneal exudation. 
The diagnosis of the chronic variety is very much more satisfactory, 
since, particularly when a pachysalpingitis exists, the tube can very 
easily be mapped out by bimanual examination, and although it is not 
by any means easy to distinguish it from the ovary, the presence of an 
irregular, tender, slightly movable mass of the size of half a lemon or 
a mandarin orange will usually enable the examiner to decide that he 
has before him the enlarged, inflamed, distorted, and adherent tube, 
encircling the probably not enlarged ovary. A certain amount of 
practice is of course required to make this diagnosis, and no amount of 
experience in digital examination will enable the examiner to detect 
with absolute certainty the exact condition of the appendages. In such 
cases their precise condition and relations can be determined only by 
the fingers introduced through an abdominal incision, and often then 
not until the adhesions have been loosened and the appendages brought 
out of the abdominal cavity. Accuracy of diagnosis is, therefore, 
impossible in a large number of these cases, and is not indeed abso- 
lutely essential either to the formation of the indication for the removal 
of the appendages or for success in the operation. The density of the 
adhesions and the possibility of detaching the appendages are really the 
important points in the operation, and these can never be foretold. A 
limited mobility of the small irregular mass found at one side of the 
uterus is a sign of its intra-peritoneal location, but this limited mobility 
does not mean the absence of adhesions or necessarily an easy detach- 
ment of the appendages. 

Frequency. — The frequency of both acute and chronic catarrhal 
inflammation of the Fallopian tubes is now recognized to be so great 
that there may scarcely be said to be a pelvic disease in the female 
which is more commonly met with than this. Our recognition of this 
frequency is, strange to say, only of very recent date. Pelvic cellulitis 
and pelvic peritonitis, and even oophoritis, were for years looked upon 



758 DISEASES OF THE FALLOPIAN TUBES. 

as the diseases which we now know to be simple inflammation of the 
Fallopian tube. True, simple, uncomplicated salpingitis is compar- 
atively rare, and oophoritis and local peritonitis usually follow or 
accompany it. The merit of having recognized the great frequency 
of the acute inflammation of the Fallopian tubes with their compli- 
cations and consequences is due above all others to Lawson Tait of 
Birmingham, England, who has done more to acquaint the profession 
with the symptoms, diagnosis, and operative cure of these diseases than 
any other one man. 

Treatment. — Even though the diagnosis may be doubtful, the treat- 
ment will be practically the same -as for acute pelvic peritonitis — 
namely, rest ; if the temperature goes above 102°, ice to the hypo- 
gastrium ; otherwise hot applications, blisters — perhaps leeches, hot 
douches. When the chronic stage has set in, frequent blistering over 
the tubo-ovarian region, counter-irritants to the vaginal vault, hot 
douches, warm alterative sitz-baths (Kreuznach brine or rock-salt), 
perhaps local galvanism for pain, may bring relief or possibly, in 
exceptional cases, a cure. Adhesions of course can never be entirely 
absorbed, and the hypertrophied tube will probably always remain more 
or less a source of annoyance to its possessor. Avoidance of sexual 
intercourse is of great importance, but probably difficult to enforce, 
since the disease is chronic. Eventually, if pain or recurrence of 
attacks of local inflammation warrant, the removal of the diseased 
appendages by laparotomy is indicated. 

Results. — An acute catarrhal inflammation of the tube not due to 
gonorrhoeal infection may recover spontaneously or under appropriate 
treatment, and the organ be restored to its normal condition. When 
once suppuration has taken place and adhesive inflammation has closed 
the fimbriated extremity (which is usually the first to be thus affected), 
and perhaps also the uterine end, the tube has become thickened, dis- 
torted, and more or less adherent to the neighboring peritoneum ; then 
of course a restoration to health is out of the question, and, even 
though the symptoms may be trifling and the pain experienced slight, 
one result is always present — namely, sterility. As this disease usually 
affects both tubes in consequence of the tendency of catarrhal inflam- 
mations to spread wherever a mucous membrane exists, and therefore 
from the endometrium to both tubes, the sterility is usually absolute, 
and no treatment whatever avails to relieve it. Still, even with 
inflamed and dilated tubes (at least temporarily dilated), conception 
may occur against all expectations. We have seen several such 
instances, where that event could be possible only on the supposition 
that at the moment of coition the tubes Avere temporarily permeable. 
Distortion and Stricture. — The conditions which produce twisting 
and occlusion of the Fallopian tube are the following : 

Acute and chronic salpingitis ; 

Pelvic peritonitis ; 

Senile atrophy ; 

Tubercle or fibrous tumors. 
As a result of this distortion and occlusion of the canal, accumulations 
of fluid frequently take place in the tube, forming either one large sac 



HYDROSALPINX. 



759 



or a number of small sacs accordingly as only the fimbriated and 
uterine extremities are occluded or as a number of constrictions occur 
along the lumen of the tube. The fluids thus imprisoned in and dilating 
the Fallopian tubes may be either mucus and muco-serum (hydro- 
salpinx), blood (hemato-salpinx), or pus (pyo-salpinx). 

Over-great distension of the tube by any of these fluids may result 
either in a rupture of the organ and the evacuation of the fluid into the 



Fig. 321. 




Perimetritis and Double Hydrosalpinx (Beigel). 
K. T., right tube; It. 0., right ovary; L. T., left tube; L. 0., left ovary; P. M., perimetritic adhesions. 

peritoneal cavity or between the layers of the broad ligament ; in the 
former instance death being a not uncommon result unless speedy 
operative interference is at hand ; in the latter, sacculation of the effused 
fluid in the pelvic cellular tissue. Or the fluid may force its way out 
through the fimbriated orifice, producing peritonitis, or into the uterine 
cavity, to be evacuated by the vagina. These tubal cysts may attain 
a considerable size, even to that of the head of a child of ten years. 
We have removed a hemato-salpinx which was even larger than that. 
[See Fig. 323, P. F. M.] Pyo-salpinx sacs seldom exceed the size of 
a small sausage or a banana. 

Hydrosalpinx. — The symptoms of hydro-salpinx are usually much 
less marked than those of the other varieties, being merely pain and 
pelvic pressure ; indeed, the history of catarrhal salpingitis and pelvic 
peritonitis of a very mild type. An examination reveals a tense, 
smooth, elastic mass of an oval shape, usually lying immediately 
behind the cervix at the bottom of Douglas's pouch. If pelvic peri- 
tonitis has existed, this elastic mass is adherent, otherwise it may be 



760 



DISEASES OF THE FALLOPIAN TUBES. 



movable. An aspirator introduced into it per vaginam under antisep- 
tic precautions shows merely a transparent watery fluid, which under 
the microscope reveals nothing but a few columnar and tessellated 
epithelia. Aspiration or incision with irrigation and drainage will 



Fig. 322. 




Double Hydrosalpinx. 

T, left hydro-salpinx ; 0, left ovary degenerated into a cyst ; T', right tube with abdominal mouth closed ; 

0', right ovary. Two-thirds natural size (Beigel). 

usually cure such cases. If the tube was adherent, the refilling of the 
sac, however, is not uncommon ; if the tube was loose, its removal by 
laparotomy would probably be the wiser plan, since the removal of the 
ovary, and perhaps of the appendages of the other side if at all involved, 
could be performed at the same time. Hydro-salpinx, as a rule, is by 
no means as serious an affection as either hemato-salpinx or pyo-salpinx, 
and seldom endangers the patient's life. 

Hematosalpinx. — Either as a result of a regurgitation of menstrual 
blood into the tube (which we consider rather improbable), or of the 
regular monthly discharge of blood from the tubal mucous membrane, 
both extremities of the canal being occluded, or, finally, in consequence 
of the rupture of the lining membrane of a tubal pregnancy, a certain 
amount of fluid blood accumulates in the Fallopian tube and distends 
it to a greater or lesser diameter. Accordingly as the effusion of blood 
is gradual the symptoms of pain, chiefly at the menstrual period, and 
of pressure in the affected side, will make themselves felt ; or, as the 



PYO-SALPINX. 



761 



effusion is sudden, the access of pain will be proportionately rapid and 
severe. The amount of blood accumulated in a dilated tube is usually 
not sufficient to produce any marked effect upon the blood-supply of 
the whole system, and hence anaemia is not a symptom of this affection. 
A physical examination reveals very similar conditions to that mentioned 
under Hydro-salpinx, except that usually there are no signs of pelvic 
peritonitis present, at least not as a direct result of the distension of 
the tube. The mass is oblong or oval in shape, or if adhesions are 
present it may assume even a globular outline. It may be entirely 
movable or more or less adherent. It usually bulges down into the 
vagina, and is easily reached by the aspirator through this canal, when 
the diagnosis of a sac containing blood is made. Whether the sac is 
the tube or the ovary will often remain in doubt until laparotomy is 

Fig. 323. 




Large Hematosalpinx, diagrammatic sketch (Munde). 

performed. If the tumor is probably intra-peritoneal, its removal by 
laparotomy is undoubtedly indicated, and should be performed as early 
as the diagnosis is made, before rupture of the sac, which may occur at 
any time, can take place. If the distension of the tube has pointed 
between the layers of the broad ligament — which fact can be suspected 
in consequence of the deep situation and comparative immobility of the 
sac — aspiration, incision, and drainage through the vagina will probably 
offer a better prospect than laparotomy. This intraligamentous devel- 
opment of hemato-salpinx is not at all infrequently produced by a tubal 
pregnancy, and the pain and faintness caused by the rupture between 
the layers of the broad ligament are usually the first symptoms to 
which the attention of the physician is called. 

Pyo-salpinx. — By pyo-salpinx we do not mean the presence of a few 
drops of pus only in the tube, but the distension of that organ by 
a considerable amount of purulent fluid, say from one to six ounces 
or more. Pyo-salpinx is usually the result of a long-continued course 
of catarrhal, and finally suppurative, inflammation of the mucous 
lining of the tube, together "with obliteration of both orifices and a con- 
siderable thickening of the walls of the canal. Little by little the 
accumulation of pus as the result of recurrent attacks of salpingitis sue- 



762 DISEASES OF THE FALLOPIAN TUBES. 

ceeds in dilating the tube until it attains the size of a breakfast sausage, 
a banana, or a closed fist. By this time usually there has been more 
or less pelvic peritonitis with exudate and adhesions, and the distended 
tube rests on the bottom of Douglas's pouch, firmly adherent to its 
surroundings. The symptoms are those of pelvic peritonitis, each 
attack being characterized by fresh pain and a rise of temperature ; 

Fig. 324. 




Large Pyo-salpinx (Cleveland). 

the attacks coming at irregular intervals, although aggravated by the 
approach of the menstrual period, the patients often being quite free 
from pain between these exacerbations. While the symptoms are those 
of recurrent pelvic peritonitis, the examining finger finds not a hard, 
immovable mass, varying from the size of the fist to that of the adult 
head, occupying part of the pelvic cavity and extending up into the 
abdomen, but a tense, tender, fluctuating swelling behind or to one 
side of the uterus, of an oblong shape, always immovable if there has 
been pelvic peritonitis — rarely, however, movable. In these respects 
pyo-salpinx closely resembles the two previous conditions, but there is 
a history of elevations of temperature, perhaps even now and then 
a chill, and the suspicion of suppuration is excited by these symptoms. 
The aspirator at once reveals the presence of pus which may or may 
not be offensive. 

Prognosis. — There is usually not much danger of rupture of the 
pyo-salpinx into the peritoneal cavity, since peritonitic adhesions render 
such an accident improbable. It is more likely to burst into the 
vagina or into the pelvic cellular tissue by ulceration of its most 
dependent portion. This possibility has led some modern gynecologists 
to pronounce true pelvic abscess or abscess of the pelvic cellular tissue 
to be merely a ruptured pyo-salpinx. It is useless to argue this point, 
since it is perfectly evident that these gentlemen go to the extreme in 
their anxiety to prove that pelvic peritonitis and salpingitis and 
oophoritis are far more common than was formerly supposed (which 
no one is disposed to doubt) — go out of their way, indeed, to deny the 



TREATMENT.— LAPAROTOMY. 763 

possibility of an inflammation of the pelvic cellular tissue, the exist- 
ence of which all who are not biassed willingly admit. If not inter- 
fered with, a pyo-salpinx may exist for some time without giving rise 
to any very serious symptoms, but so long as present the patient is 
liable to a recurrence of pelvic peritonitis, salpingitis, and an increase 
in the size of the pyo-salpinx at any time, and eventually, it cannot be 
denied, an upward rupture into the pelvic cavity with fatal peritonitis 
may result. 

Treatment. — When the diagnosis of a purulent accumulation in the 
tube has been made (and we will here repeat that it is not always possi- 
ble even with the aspirator to differentiate between an abscess in the 
ovary and a pyo-salpinx), there is but one question as to the treatment 
to be employed — namely, the speedy evacuation of the contents of the 
abscess. There is no difference of opinion upon this question ; but as 
regards the proper means and the proper channel by which the pus 
should be evacuated there may exist a variety of opinions. The 
majority of operators, especially those who, so to speak, make a 
specialty of abdominal section, will undoubtedly reply that the only 
proper way to treat a pyo-salpinx is to remove the diseased tube bodily 
by means of an abdominal incision ; and probably these gentlemen are 
right in by far the large majority of cases. Certainly, whenever the 
pus-tube is movable, and particularly when the appendages of both 
sides are diseased, even though there may be pus only on one side, the 
removal of the diseased appendages — that is, both ovaries and tubes — 
should be performed without delay. If, however, the pus-tube is situ- 
ated deep in Douglas's pouch, is firmly adherent there, is easily reached 
through the vagina, and the appendages on the other side are apparently 
normal, the propriety of opening and draining the abscess through the 
vagina may well be entertained. It is true, such pus-sacs are usually 
tedious in closing and the abscess may discharge for months ; but we 
have been very successful in treating a number of cases of this kind 
through the vagina, keeping a hard-rubber, silver, or glass tube in the 
abscess-cavity by means of silver-wire stitches which were passed 
through small openings in the vaginal edge of the tube ; by frequent 
irrigations, and by ; occasional cauterizations of the pus-cavity with 
the stick of nitrate of silver we have eventually succeeded in effecting 
a closure of the abscess. [I was enabled to achieve the same result by 
applications of iodized phenol in a young girl of sixteen, in whom, to 
be sure, a secondary attack of pelvic inflammation was produced by 
these applications, but which resulted in a permanent closure of the 
tubal abscess. — P. F. M.] 

Laparotomy for Diseased and Adherent Tubes. — The technique of 
this operation differs but little from that already described under 
Ovariotomy. The chief distinction lies in the fact that the abdominal 
cavity lias not been distended and the abdominal walls are rigid and 
firm. This renders the first steps of the operation, including the open- 
ing of the peritoneal cavity, rather more difficult, and implies extra- 
ordinary care on the part of the operator to avoid wounding intestine 
or omentum which may lie close beneath the peritoneum. Besides, the 
manipulations in removing the appendages and the introduction of the 



764 DISEASES OF THE FALLOPIAN TUBES. 

sutures to close the abdominal wound are rendered more difficult by the 
rigidity of the abdominal walls. After opening the peritoneal cavity, 
the incision being made only of sufficient length to enable two fingers 
to be introduced into the abdomen, these two fingers seek the fundus 
uteri, and then proceed to map out the appendages and to peel them 
loose from their attachments if such are present, taking care to avoid 
undue force or haste, always acting on the principle that it is better 
to be slow and sure than rapid and uncertain. The appendages will 
usually be found attached to the bottom of Douglas's pouch and to the 
posterior fold of the broad ligament. They can be peeled loose by 
gradually inserting the fingers between the coils of the tube, finding 
the least resistant spot, and gently sweeping the finger-tips about 
until the whole organ is detached. If there is pus in the tube, it may 
rupture upward and its contents escape among the intestines. The 
appendages should then be peeled loose and brought out of the abdom- 
inal incision as rapidly as possible, clamped, tied off, and removed as 
described under Ovariotomy, and the abdominal cavity then be washed 
out thoroughly with warm Thiersch's solution. If there is any fear of 
oozing, or doubt as to whether the abdominal cavity is perfectly clean, 
a drainage-tube may be introduced, but if we have found the bottom 
of Douglas's pouch, as explored by repeated sponges on holders, fairly 
clean and dry, we have usually omitted the drainage-tube and closed 
the abdominal cavity, and have had no occasion to regret our action. 
The after-treatment is the same as after ovariotomy. 

The proposal has recently been made by several operators, notably 
Polk, in cases where the adhesions are slight and the tube is easily 
detached, to endeavor to save the organ and restore it to its healthy 
condition by opening the fimbriated orifice with a fine probe and pass- 
ing this through into the uterine cavity, so as to render the tube again 
permeable. Any secretion contained in the organ should be gently 
expressed, the organ carefully cleansed, and returned to the abdominal 
cavity. Polk, we believe, has practised this procedure a number of 
times, with what ultimate results we are unable to say ; that is to say, 
we are not aware whether the patients were cured and eventually con- 
ception took place. Munde' has made the theoretical suggestion 1 to 
disinfect and distend the canal of the tube after detaching it from its. 
adhesions by injecting a mild solution of bichloride of mercury through 
it from the fimbriated orifice before dropping it. It will be the task 
of conservative surgeons to work out this problem, which possibly has 
a future before it. 

The experience of Tait chiefly, as well as that of other less prolific 
operators, has been that if the appendages of one side are diseased by 
chronic catarrhal, and mainly by purulent, inflammation, while those 
of the other side appear as yet healthy, it is still wiser to remove those 
of the apparently healthy side also, since, in those cases where they 
have been saved and the attempt made to give the patient an oppor- 
tunity to conceive, almost invariably the patient has returned within 
a year or two for disease of those organs, and a second laparotomy was 

1 See "A Year's Work in Laparotomy — Forty-five Operations," Am. Journ. Obstet., 
Jan. and Feb., 1888. 



RESULTS OF THE OPERATION. 765 

required. Of course if the patient should very anxiously desire chil- 
dren and is willing to take the responsibility of a possible second lapa- 
rotomy, she should be allowed the privilege of deciding whether both 
appendages should be removed or not, the case having been properly 
stated to her before the operation was begun. A second lapa- 
rotomy, be it mentioned, does not offer, as a rule, any particularly 
greater dangers than the first, with the possible exception of adhesions 
of intestines or omentum to the anterior abdominal wall, injury of 
which organs — this possibility being known — can thus readily be 
avoided. 

The Indications for Laparotomy in Diseased Appendages depend 
entirely upon the amount of pain the patient suffers, upon the degree 
of disease of the appendages as recognized by careful bimanual palpa- 
tion, and upon the failure of palliative treatment to afford relief. This 
question must always be left for each individual operator to decide 
after mature deliberation in each separate case. No hard-and-fast 
rules can be laid down except such as are based upon the indications 
just mentioned. We believe that this operation has been performed 
far too frequently, and that many tubes and ovaries have been sacri- 
ficed which could possibly have been saved. It is very tempting to 
perform laparotomies when they can be accomplished with such com- 
paratively slight risk as is now the case with this operation, and the 
sufferings of the patients, many of whom are of an intensely hysterical 
and neurotic type, can be so easily exaggerated and over-estimated that 
a justifiable indication for the operation is readily found ; and for these 
very reasons would we again warn against the indiscriminate, hasty, 
and routine performance of this operation. 

Results of the Operation. — We have just stated that laparotomy 
performed for the removal of diseased appendages is accompanied by 
so little risk that many have undertaken it lightly without, we fear, 
justifiable reasons. In the hands of Lawson Tait, who has done more 
to familiarize us with the diseases of the appendages and their operative 
treatment than any other man, the mortality from this Operation has 
been so slight that we believe he has performed 147 successive opera- 
tions without a death. In the hands of less dextrous, and perhaps less 
lucky, operators the mortality has been so trifling that from 50 to 75 
operations have been performed successively without a fatal result. 
The average mortality would probably not be more than from 3 to 5 
per cent. Therefore, so far as the immediate results are concerned, 
nothing better could be desired ; but it is our duty to acknowledge to 
ourselves, and so to inform our patients before the operation, that in a 
certain proportion of these cases the symptom for which the operation 
was performed- — namely, the pelvic pain — is not relieved, but persists 
for a number of months, perhaps for years, after the operation, in spite 
of the fact that the appendages were thoroughly and carefully removed. 
We cannot give exact figures as to the number of cases in which this is 
likely to occur, but we recollect enough to justify us in cautioning our 
readers against promising their patients an entire, immediate, and com- 
plete cure as soon as they recover from the operation. Furthermore, 
the persistence of menstruation for a number of months after the ope- 



66 



DISEASES OF THE FALLOPIAN TUBES. 



ration is by no means uncommon, and this also should be told the 
patients to prevent their thinking that the operation has either not 
been at all or carelessly performed. (For details as to the indications 
and results of laparotomy for this particular disease we refer to the 
writings of Tait, Saenger, Wylie, Price, and others.) 

Palliative Treatment. — Contrary to the usual order, we have spoken 
of the radical treatment of diseased appendages first, chiefly because the 
palliative treatment is so very unsatisfactory, and oifers comparatively 
so little hope of relief, that we have not thought it worth while to spend 
much time in discussing it. In cases of not too long standing, local 
counter-irritation by tincture of iodine to the vaginal vault, glycerin 
tampons, hot douches, iodine, and blisters to the ovarian region of the 
abdomen ; further, brine sitz-baths, and for the relief of pain and occa- 
sional interstitial inflammation the mild galvanic current. These are 
the means which we should advise, practise, and always recommend in 
every case where they had not already been conscientiously tried for at 
least several months. In no case would we perform laparotomy where 
these measures had not been employed first. These remarks, of course, 
apply entirely to chronic catarrhal salpingitis with thickening and adhe- 
sions of the tubes and ovaries, and not to serous, bloody, or purulent 
accumulations in the tubes. 

Displacements. — The tubes may pass with hernial protrusion into 
the inguinal or crural openings, and in case of inversion of the uterus 
may descend into the cavity of the displaced organ. It is generally in 
company with the ovary that the tube leaves its place, but at times it 
descends alone. Dr. Scholler 1 reports an instance in which, in a child 
who died twenty days after birth, a tumor was discovered which extended 

Fig. 325. 




Pyo-salpinx, with adhesions; ovary still distinguishable (Munde). 



from the inguinal region to the right labium, and contained the Fallopian 
tube, which was non-adherent. A crural hernia of the tube alone which 
ended fatally is likewise recorded by M. Berard. 

Prof. Rokitansky 2 and Dr. Turner of Scotland have both drawn 
attention to severance of the tube from the ovary by traction from 

1 Courty, op. cit. 2 Sydenham Soc. Year-Book, 1861. 



OTHER DISEASES OF THE TUBES. 



767 



increased weight of the latter or from false membranes. The former 
cites twelve instances in support of the fact. 



Fig. 




Pyo-salpinx, with oophoritis and universal adhesions masking the ovary (Munde). 

Other Diseases of the Tubes. — In addition to these diseases the tubes 
are sometimes affected by tubercle, cancer, and fibrous tumors. 

Tuberculosis of the tubes is by no means as uncommon as was 
formerly supposed, and primarily it is rarely met with, the few cases in 
which it occurred having been attributed to the direct infection of the 
genital tract by the tubercular bacilli carried in by the semen of a 
tubercular man, who perhaps was suffering both from pulmonary tuber- 
culosis and a tuberculous testicle. Usually tuberculosis of the tube is 
secondary to tubercular disease in other organs of the body, chiefly 
tubercular peritonitis. The disease manifests itself by a thickening 
of the tubes, which are filled with caseous material, the walls showing 
evidence of caseous inflammation. The tubercle bacilli are readily 
detected in the secretions of the tube. We have seen tuberculosis of 
the tube in several instances where we operated for tubercular perito- 
nitis, and it was found that the small tumors which were detected in the 
ovarian regions were the tuberculous tubes and ovaries matted together 
with the intestines, the peritoneal covering of which was also studded 
with tubercular deposits. 

The diagnosis of tuberculosis of the tubes is exceedingly difficult. 
Only when an enlargement and adhesion of the tubes are detected by 
bimanual palpation, together with tubercular peritonitis or tubercular 
disease of some other organ of the body, may such a diagnosis be pre- 
sumptively formed. An examination of the uterine secretion for tubercle 
bacilli might possibly settle the question. 

The treatment is unsatisfactory, since opportunity to remove the 
tubes primarily affected by tuberculosis will scarcely ever be offered, 
and their removal when complicated by tuberculosis of other organs 
will of course be merely palliative. 

Cancer and fibrous tumors of the tube are rare, and require no spe- 
cial mention in a textbook of this kind. 

49 



768 



EXTRA-UTERINE PREGNANCY. 



Papilloma of the Tube. — Doleris 1 reports a probably unique case 
of this disease occurring in a woman who had suffered from pain in the 
pelvis and a sero-sanguinolent discharge for a number of months. 



Fig. 32/ 




Papilloma of Tube (Doleris). 

Examination showed a tumor of the size of a large orange on one 



side of the uterus. 
Fig. 327. 



The operation disclosed the growth shown in 



CHAPTER XLVII 



EXTKA-UTEEINE PEEGNANCY. 

It is evident that to condense into the narrow limits of a short chap- 
ter a subject which would require a volume for its extended considera- 
tion involves of necessity a superficial review of its essential points only. 

It may even be thought by some that this subject is out of place in 
a work upon gynecology, and that it should have been left for one 
devoted to obstetrics. Its admission here is proof of the fact that we 
do not share this feeling. Ectopic gestation, although theoretically 
falling in the domain of the obstetrician, in reality almost always claims 
the attention of the gynecologist, from the fact that the existence of 
pregnancy is in these cases very generally not recognized, the patient 
being supposed to suffer from some pelvic tumor or obscure uterine or 
ovarian disorder. It is very frequently necessary to differentiate it 
from a variety of disorders which will soon be mentioned, and even its 
treatment involves rather a familiarity with the resources of gynecology 
than with those of obstetrics. 

Definition and Synonyms. — Extra-uterine pregnancy, extra-uterine 
or ectopic gestation, signifies the fixation and development of the 
impregnated ovum outside of the uterine cavity. 

1 Journ. de Med. de Paris, Feb. 23, 1891. 



VARIETIES— ETIOLOG Y. 769. 

Varieties. — For the physiologist and pathologist there are many 
varieties of this abnormal gestation ; for the gynecologist there are but 
three. For him the tubo-ovarian, tubo-abdominal, ovarian, and some 
other varieties are niceties beyond the appreciation of diagnosis, and 
he is forced to limit himself, as far as practice is concerned, to the clas- 
sification of all varieties into — 1st, tubal ; 2d, interstitial ; and 3d, 
abdominal pregnancies. These by rational and physical signs he may 
differentiate from each other, and in certain cases base the propriety of 
surgical interference upon his conclusions. These, and these only, then, 
are the varieties which we shall consider in this chapter. 

Tubal pregnancy, the most dangerous of all varieties of extra-ute- 
rine gestation, consists in the arrest of the impregnated ovum in the 
Fallopian tube and its development there. It may be that instead 
of being absolutely in the tube the fructified ovum may develop just 
where the fimbriated end of the tube clasps the ovary. 

Interstitial pregnancy consists in an advance of the ovum through 
the tube until it begins to pass through the uterine wall. Then, an arrest 
taking place before the ovum enters the uterus, it attaches itself, distends 
the parenchyma of the uterus to make its nidus, and causes it to protrude 
partly toward the uterine cavity, partly toward the abdominal. 

In abdominal pregnancy one of two things occurs : either the tube 
holding the impregnated ovum in its grasp breaks away from its ova- 
rian attachment, falls into the abdominal cavity, and remains there, 
while the ovum, casting out tentacula, attaches itself to the peritoneum 
and grows; or, as some suppose possible, the impregnated egg falls out 
of the grasp of the tube, and, getting its nourishment from the perito- 
neum, develops independently of the lining membrane of the uterus 
which extends throughout the tubes. 

Etiology. — It is a fact universally accepted that in the human female, 
as in the lower order of animals, impregnation of the ovule often occurs 
at or near the ovary. In some cases, by a stricture in the tube due to 
lessening of its calibre by inflammation, the development of a little 
tumor, or contraction of lymph poured out by pelvic peritonitis, an 
obstruction is offered to the progress of the ovum toward the uterus. 
In contact with a mucous membrane closely resembling that of the 
uterus, it at once accommodates itself to its vicarious quarters, attaches 
itself, forms a placenta, and steadily grows. There are many points in 
pathology concerning which no one has a right to an opinion who has 
not made researches of a more or less personal character in regard to 
them. The pathology of extra-uterine pregnancy is one of them, and, 
although our experience in reference to this condition is quite large, as 
we shall soon show, Ave express ourselves upon it with great hesitation. 

Although extra-uterine gestation has been divided by pathologists 
into abdominal, tubal, ovarian, interstitial, tubo-abdominal, and tubo- 
ovarian, it seems highly improbable that the ovum at the moment of 
its impregnation Could attach itself to any other tissue than the lining 
membrane of the uterus, which is so especially constructed to accommo- 
date it. Once having undergone development in this connection, how- 
ever, it rapidly invades adjoining structures, the omentum, peritoneum, 
etc., and forces them to nourish it. 



770 



EXTRA- UTERINE PREGNANCY. 



Pathology. — Should the arrest of the ovum have occurred in one 
of the tubes, it develops rapidly and endeavors to furnish a uterus for 
the growing child. But the muscular structure of the tubes, being 
scanty compared with that of the uterus, although it develops to accom- 
modate its contents, gradually grows thinner and thinner under disten- 
sion until, toward the end of the first, second, or third month, it usually 

Fig. 328. 




Tubal Pregnancy. 

A, Uterus laid open on the anterior surface; B, part of the decidua still adherent to the right uterine 
cornu; C, decidua, nearly entire, expelled before death: D, right tube and ovary, normal; E, E, mar- 
gins of artificial opening in the left tube; F, umbilical cord ; G, placenta; H, pavilion of the left 
tube; I, vascular plexus, ramifying over the tubal covering of cyst, from which the hemorrhage 
occurs on its rupture; J, vagina. 



ruptures, and the contents of the ovum, as well as much blood escaping 
from the ruptured vessels of the tube, escape into the peritoneal cavity. 

A true hematocele is thus created, the patient generally becoming- 
collapsed and dying, and very rarely escaping by absorption of the 
blood and by encapsulation or discharge of the foetus. Veit 1 declares 
that about one-fifth of all cases of hematocele are due to the rupture 
of tubal pregnancies, and that recoveries occur under these circum- 
stances much more commonly than is generally supposed. We do not 
agree with him as to the frequency of this cause of hematocele, but we 
are quite sure that we have seen it thus produced, and have seen recov- 
ery follow. These are the cases of hematocele which are classed by 
Barnes under the name of "cataclysmic." As a rule, the violence of 
their onset entitles them to that name, but it is highly probable that 
some of those occurring at early periods of gestation develop with less 
violent and overwhelming symptoms. 

Hecker reports 45 cases of tubal pregnancy : in 26 cases rupture 
occurred in the first month, in 11 cases in the third month, in 7 cases 
in the fourth, and once in the fifth month. Spiegelberg 2 reports a case 
of an ovum advancing to maturity in the tube. 

Interstitial pregnancy is much less frequent and less dangerous than 
the variety just mentioned. It is much more likely to advance to full 
term, and while it may produce death by rupture and discharge into 
the peritoneum, it may, as in Thomas's fourteenth case and in one 



1 Deutsche Zeit. far Prakt. Med. 

2 Arch.f. 6tyn.,*Bd. i. p. 400. 



No. 49, 187£ 



PATHOLOGY. 



771 



observed by Munde, discharge into the uterus and be expelled through 
the natural passages. Similar cases are reported by Doran, Polk, Hicks, 
Poppel, Monteil, Pows, and Parkes. Dr. Lenox Hodge once suc- 
ceeded in recognizing the existence of such a case at full term, cut 



Fr«. 329. 


:: ** .'•■'■ 


' '"% \ Jc - ■.. . 

pi ■ \ v x 

■/ ) J 


f W\ I j' _„^-^ ^ <■ 4 / > / 


_ 


<iM"t 


IPP 1 *^ 


» — us - 1 ■ \» . 


; >**■■" ■) Q* 



Interstitial Pregnancy (Cleveland). 

7 c, left cornu ; I o, left ovary and tube ; c I, corpus luteum of pregnancy in left ovary (erroneously marked 
Ic in plate) ; PI, placenta; Am, amnion; u e, superior extremity of uterine cavity in left horn; d, de- 
cidua; re, undeveloped right cornu; io, internal os ; r o, right ovary; c, cyst. 

through the layer of parenchyma which shut the foetus off from the 
uterus, and conducted the case to a successful issue. 

Although not attended by as great dangers as attach to tubal and 
interstitial pregnancies, the abdominal variety is a most serious aberra- 
tion from normal gestation and one which commonly destroys life. In 
the first two forms the rapidly-developing ovum is imprisoned in tissues 
which are inapt for great distension, and which rupture under its inllu- 



772 EXTRA-UTERINE PREGNANCY. 

ence. In the third the foetal ball has at its disposal for expansion and 
growth the whole peritoneal cavity, the placenta encroaching in its 
search after nutriment upon the bladder, the omentum, the intestines, 
and any portion of the peritoneum' within its reach. The events of 
this form of pregnancy are the following : First, the foetus, unnaturally 
attached and nourished, may die in the early months of its life, become 
encysted, and in time be cast off through the rectum, the bladder, or 
through the abdominal walls. Second, the pregnancy may advance to 
the end of the ninth month, when, labor coming on, Nature makes a 
persistent effort to expel the child, but, on account of there being no 
way of exit, fails, and the child, with its envelopes, is retained, and, 
becoming encysted, remains in its nidus for years, creating no disturb- 
ance by its presence. Third, the child, shut up in its unopened shell, 
acts as a foreign body, creates suppurative action in its envelopes, and 
becomes surrounded with pus in place of liquor amnii. Or, the liquor 
amnii being absorbed, the foetal bones become closely hugged by the 
walls of the cavity which contains them, and act as an intense irritant, 
which sets up formation of pus, and in this way leads to hectic fever 
from absorption of septic material. 

Hecker found that out of 132 cases of abdominal pregnancy, 76 
terminated in recovery. Recovery took place in 28 cases after expul- 
sion of foetus per anum, in 17 cases after formation of lithopaedion, in 
15 cases after elimination through the abdominal wall, in 11 cases after 
laparotomy, in 3 cases following vaginal section, in 2 cases from unde- 
fined causes. Death followed from septic infection in 18 cases, perito- 
nitis in 12 cases, operations in 12 cases, rupture and hemorrhage in 7 cases, 
fecal vomiting in 2 cases, dropsy in 1 case, cause not defined in 4 cases. 

Causes of Death. — The causes of death in the various forms of 
extra-uterine pregnancy may thus be presented : 
Hemorrhage ; 
Septicaemia ; 
Peritonitis ; 
Perforation of important viscera by bone. 

Symptoms. — The suspicion of extra-uterine pregnancy is usually 
created in one of the following ways: 1st. A woman who has passed 
over one, two, or three menstrual epochs is suddenly seized with the 
symptoms of hematocele, agonizing pelvic pain, faintness, coldness of 
extremities, bathing of face w T ith cold sweat, rapid and feeble heart- 
action, and nausea and retching. She dies of anaemia from internal 
hemorrhage, of peritonitis, or of septicaemia; or she gets well, the dia- 
gnosis of pregnancy is regarded as a mistake, and she is said to have 
recovered from hematocele which was the result of temporary suppres- 
sion of menstruation. 

2d. A woman who supposes herself to be pregnant becomes alarmed 
by the development of one, two, or three sets of abnormal symptoms : 
(a) the occurrence of irregular, immoderate, sudden, and excessive 
gushes of blood ; (b) the rapid and disproportionate enlargement of the 
hypogastrium ; or (<?) the manifestation of a dull, grinding pain, fixed 
in one iliac fossa or extending thence down the thighs, and, as time 
passes, becoming markedly paroxysmal and spasmodic. 



DIFFERENTIATION. 773 

Suspicion is thus excited, not of the existence of this vice of gesta- 
tion, but of something being wrong, and a careful examination by 
rational and physical signs is instituted. Should such examination be 
made after rupture of the vicarious uterus and escape of its contents 
into the peritoneal cavity, the ordinary physical signs of hematocele 
will be detected, and to their enumeration in the chapter devoted to 
that subject the reader is referred. 

Physical Signs. — Besides the symptoms mentioned pointing to the 
advisability of a physical examination, the uterus is" usually found 
enlarged, lifted up in the pelvis, and pressed forward or laterally by a 
tumor which exists posterior to it or on one side. This tumor is found 
to be nearly immovable, very slightly sensitive upon pressure, and 
marked by a peculiar degree of hyperemia, which gives, to an exag- 
gerated degree, the violet hue of gestation to the vagina. It is marked 
by a very rapid growth, so that a week's watching will show a decided 
increase in its dimensions. 

The tumor alone would not furnish sufficient grounds upon which to 
found a diagnosis of ectopic gestation, but a rapidly-growing pelvic 
tumor accompanied (a) by the gastric and mammary symptoms of preg- 
nancy, (b) by cessation of menstruation, (e) by enlargement of the ute- 
rus, (d) by the purple hue of the vagina, and (e) by the detection of 
ballottement in the tumor, would do so. 

Differentiation. — The conditions with which extra- uterine gestation 
is most likely to be confounded are the following : 

Uterine fibroma or fibro-cyst ; 

Cyst of ovary or broad ligament ; 

Hematocele ; 

Double or bicorned uterus, with impregnation of one side ; 

Normal pregnancy with retroflexion ; 

Pelvic abscess. 
The uterus is in these cases lined by decidua, and it is almost as 
much enlarged as in normal pregnancy. Before any decision is arrived 
at it is often wise to dilate the cervical canal with tents, so that the 
finger may be introduced to the fundus. By this measure normal preg- 
nancy, if it exist, is interfered with,, but the exigency requiring imme- 
diate diagnosis is so great that this disadvantage must be accepted. 

Dilatation of the cervical canal having served to exclude normal 
pregnancy, while all the symptoms of pregnancy exist with marked 
enlargement and softening of the uterus, and with the presence of a 
suspicious tumor in the .pelvis, the probabilities in favor of extra-uterine 
foetation become strengthened. Still, the differentiation of this from the 
other conditions mentioned remains to be established, and it is often 
very difficult. It is only by the most careful consideration, patient 
research, and judicious delay that it can usually be accomplished. 
While these are being exercised rupture of an extra-uterine foetal nest 
may occur, and a fatal issue be the consequence. 

In some cases, ballottement, clear and distinct as that which is got- 
ten in normal pregnancy, lends us its aid and makes diagnosis certain : 
in others the aspirator clears up the case : while in others still — where. 
for example, the question lies between a cyst of the broad ligament 



774 EXTRA-UTERINE PREGNANCY. 

and extra-uterine pregnancy — cutting into the sac by means of the 
incandescent knife will combine diagnosis and treatment in a most 
satisfactory manner. 

[Let me illustrate the difficulties and methods of diagnosis under these 
circumstances by the relation of three cases : 

Case 1. — Mrs. A suddenly ceased menstruating, and for three 

months suffered from nausea and vomiting, and pelvic pain extending down 
one thigh, and became so enfeebled and emaciated that she could not stand 
without support. She came to me from Peekskill, and upon examination I 
found the uterus elevated and pushed to one side by a fluctuating tumor in 
one iliac fossa. Drs. Fordyce Barker and Noeggerath saw her in consulta- 
tion with me, and we could not decide whether it was a case of amenorrhoea 
with cyst of the broad ligament or tubal pregnancy. Immediate action was 
necessary, and I cut through the vaginal walls with Paquelin's thermo- 
cautery, and found the former condition existing. 

Case 2. — Mrs. B was brought to Dr. Marion Sims and myself to 

decide as to the cause of irregular menses, with violent pain in left iliac 
fossa. Physical examination showed uterus pushed upward and laterally by 
a tumor attached to its left horn. The question lay between interstitial 
pregnancy and inflammatory product in left broad ligament. To decide it 
we fully dilated the uterus by tents, introduced the finger fully to the fundus, 
and found the latter condition to exist. 

Case 3. — Mrs. C consulted me on account of a soft, fluctuating 

tumor posterior to the uterus, accompanied by cessation of menstruation. I 
was doubtful whether it was a fixed ovarian cyst, a hematoma, or an abdomi- 
nal pregnancy. Her symptoms were so urgent that I dared not delay for 
time to solve the question, so I passed through the mass a strong interrupted 
current, which would have killed a foetus had one existed. But it proved 
to be a hematoma, and was subsequently discharged through the rectum. — 
T. G. T.] 

The question of diagnosis being a very momentous one, it is gen- 
erally advisable to settle it by crucial tests which are not attended by 
great danger if the case be not one of pregnancy, and might prove cura- 
tive if it were so. 

Very often w T e hear of physicians being blamed on account of fail- 
ure of diagnosis in those cases which suddenly die from rupture. Every 
medical man who countenances such a charge demonstrates his want 
of experience or his want of professional loyalty by so doing. Very 
often there is nothing in these terrible cases to excite suspicion ; very 
generally nothing to decide us positively even when suspicion is 
excited. 

Symptons of Approaching Rupture. — The part containing the foetus 
and constituting a vicarious uterus begins to contract, and miniature 
uterine efforts show themselves in increasing severity ; a bloody flow 
takes place from the cervix, and very commonly a small piece of decid- 
uous membrane is expelled. These symptoms will very probably be 
supposed to point to abortion, and the case is usually allowed to proceed 
until the suddenly developed symptoms of rupture of the sac serve to 
open the eyes of the practitioner to the truth, or at least excite in his 
mind a strong suspicion of it. 



PROGNOSIS. lib 

Recognition of the Varieties. — Nothing is easier in a written descrip- 
tion or in the lecture-room than to point out the means of differentiating 
the three great varieties of ectopic gestation — abdominal, interstitial, 
and tubal. Nothing is more difficult, as every man of large experience 
in this difficulty will agree, than to do this at the bedside. In general 
terms, it may be said that the interstitial form is very rare, that the 
tumor consists of an irregular enlargement of the uterine body, and 
that the tumor moves with the uterus while at the same time this organ 
is empty ; that tubal pregnancy gives an enlargement at the side of 
the uterus, yields ballottement more generally than the other forms, 
and is marked by a tumor somewhat separated from the uterus, and 
which does not decidedly move with it ; and that abdominal pregnancy 
is generally detected late, at a period when the rolling of the child's 
body in the abdomen can be detected, while at the same time the uterus 
is found to be empty. 

We do not pretend to offer these differences between the varieties as 
universal and reliable means of differentiation. Indeed, no such means 
will be offered by any one whose experience is large, for such experience 
must have taught him that none such exist. We have seen three cases 
of interstitial pregnancy, and have relied in the description which we 
have given very largely upon the signs presented in these. 

[I mistook a pregnancy in the right horn of a bicorned uterus first for 
a tubal pregnancy, then, on opening the abdomen, for an interstitial foetation, 
and not until the sound was passed toward the left three, and toward the 
right five, inches was the correct diagnosis made. The woman aborted and 
recovered. 1 — P. F. M.] 

Prognosis. — Whatever be the variety, the period, or the circum- 
stances connected with this vice of gestation, the prognosis is bad. 
True, a large number of woman escape death, but this fact does not 
contradict the statement just made. The prognosis is most favorable 
in abdominal pregnancy when adhesion has occurred from death of the 
foetus and subsequent inflammation between the sac-wall and the parietal 
peritoneum ; less favorable where no such adhesion exists arid the peri- 
toneal cavity is free in front of the foetal shell. It is more favorable 
in interstitial than in tubal pregnancy, and least favorable in the purely 
tubal variety. In the tubal form it is much less favorable if the foetus 
be living than if it be dead. Kiwisch 2 reported 100 cases of extra- 
uterine pregnancies, with 18 recoveries ; Puech, 100 cases of tubal 
pregnancy, 98 cases of rupture of tube, 2 of rupture of vein of broad 
ligament, 1 recovery ; 199 cases of elimination of foetus in the ovarian 
and abdominal form, 146 recoveries. (See Courty, p. 996.) 

[As my experience in this condition has been quite large, I report it in 
full in the subjoined table: 3 



1 Am. Joum. ObsL, 1890. 

2 Spie 

3 [I h 
T. G. T.] 



2 Spiegelberg, Lehrbuch der Geburtshulfe, 1877, p. 323. 

3 [1 have met with a number of additional eases sinee this table was constructed. 



776 



EXTRA-UTERINE PREGNANCY. 



° £ 

52=5 » 


With whom seen. 


Variety. 


Remedial measures 
adopted. 


Termination. 


1 


Dr. Mouraille. 


Tubal. 




Death from rupture. 


2 


Dr. Henschel. 


Tubal. 


Aspiration by Dr. 
Thomas. 


Death from septicae- 
mia. 


3 


Dr. Henschel. 


Tubal. 




Death from rupture. 


4 


Dr. Giberson. 


Tubal. 




Death from rupture. 


5 


Dr. J. L. Brown. 


Tubal. 


Aspiration by Dr. 
Thomas. 


Death from rupture. 


6 


Drs. Green and 
Crane. 


Tubal. 


Elytrotomy by Dr. 
Thomas by galvano- 
caustic knife and de- 
livery of foetus. 


Recovery. 


7 


Drs. Coates and 
Barker. 


Abdominal. 


Laparotomy by Dr. 
Thomas. 


Recovery. 


8 


Dr. Chas. Young. 


Abdominal. 


Laparotomy by Dr. 
Thomas. 


Recovery. 


9 


Dr. J. Hadden. 


Abdominal. 


Laparotomy by Dr. 
Thomas. 


Recovery. 


10 


W. J. Walker. 


Abdominal. 


Discharged by vagina. 


Recovery. 


11 


Olcott. 


Abdominal. 


Discharged by rectum. 


Recovery. 


12 


Drs. Barker, 
Fisher, Lusk, 
and Metcalfe. 


Tubal. 




Death from rupture. 


13 


Dr. Green. 


Interstitial. 





Died years afterward 
from pneumonia. 


14 


Drs. Emmet and 


Interstitial. 


Life of foetus destroyed 


Recovery. 




McBurney. 




by electric current ; 










foetus discharged 
through uterus. 




15 


Drs. Peaslee and 


Abdominal. 


Incision by Dr. Peas- 


Death from septicae- 




Janvrin. 




lee. 


mia. 


16 


Dr. W. Frankel. 


Abdominal. 




Still living. 


17 


Dr. Harrison. 


Abdominal. 


Electric-current now 
being used. 


Patient living. 



Of these 17 cases, 2 were interstitial, and both recovered; 7 were tubal, 
and 1 only recovered ; 8 were abdominal, and 5 recovered ; while 2 are still 
doubtful. Out of the 17 cases, 10 recovered and 7 died. This fact, how- 
ever, must be noted : 2 patients still live, and the diagnosis may be incorrect 
in their cases, or they may yet die of the condition if the diagnosis be cor- 
rect. Out of the 17 women thus affected, 9 were submitted to surgical pro- 
cedures, and out of these 6 recovered and 3 died. — T. G. T.] 

Treatment. — In dealing with the treatment of extra-uterine gesta- 
tion we are possessed by a strong desire to avoid even the appearance 
of dogmatism. There is none in the whole list of subjects, obstetrical 
and gynecological, about which so little is absolutely settled and upon 
which practical men differ so widely. At one extreme stand able and 
conservative practitioners who appear to favor the position that, as a 
very general rule, we should stand calmly by with folded arms and 
accept without effort or resistance the terrible chances of death which 
attend these cases. At the other we see enthusiastic ones with strong 
surgical proclivities, who would apparently resort to laparotomy in every 
case in which diagnosis is possible. On a middle ground, one lying 
between these extremes, the truly conservative surgeon will find his 
appropriate position. 



TREATMENT. Ill 

Let us in the beginning recognize the fact that, do what we will — 
remain utterly inactive or use the greatest surgical enterprise — the issue 
of these unfortunate cases will very likely be bad. And let every sur- 
geon be sure that he does not shirk a dangerous operation because he 
fears the odium which will probably attach to a fatal result, and which 
he would avoid if he simply allowed his patient to die without an effort. 
He who cannot bear unjust censure and endure without complaint an 
odiunl which he does not deserve was not born to be a surgeon, one 
of the greatest functions of whose life this is ; and under the grave 
responsibilities which attach to the conduct of a case of ectopic gesta- 
tion it is the bounden duty of such an one to place his patient's interests 
in stronger hands. The statement is true everywhere in surgery, but 
nowhere is its truth more strikingly apparent than in these cases, that 
every personal consideration, every private interest, should yield to the 
good of the patient. 

One point which may be regarded as entirely settled in the treat- 
ment of extra-uterine pregnancy is this : a secondary operation for dis- 
charge of the contents of the foetal sac is always safer than a primary 
one. But its antithesis must likewise be recognized — it may become 
hazardous to discard a primary operation and to expose a patient to the 
delay involved by waiting for a secondary one. The rule for inter- 
ference should then be this : Delay is wise so long as it is the offspring 
of prudence ; it is culpable as soon as it becomes the dictate of timidity 
and indecision. 

The only way in which justice can be done to this subject is by sup- 
posing certain conditions, differing widely from each other, in which the 
patient may be seen : 

(a) The tumor being low in the pelvis, fluctuation distinct, and the 
diagnosis of extra-uterine pregnancy well established, the life of the 
foetus should be destroyed by means as certain and as free from danger 
as possible. There are three methods by which this may be clone : 1st, 
by passing through the tumor a strong interrupted current, one elec- 
trode in the rectum and the other on the most prominent part of the 
tumor, the judgment of the practitioner being the guide as to the 
power and duration of the current; 2d, by injecting through the 
vaginal or abdominal walls, by means of a long and slender hypo- 
dermic needle, ten to fifteen drops of Majendie's solution of morphia 
directly into the sac ; and, 3d, by drawing off the liquor amnii by a 
very small aspirator needle with antiseptic precautions. 

1. Electricity. — Bachetti was the first in 1853 to treat and arrest a 
tubal pregnancy by electro-puncture with the faradic current; Braxton 
Hicks in 1866 employed the faradic current in a case of abdominal 
pregnancy, then punctured per vaginam, the patient dying of internal 
hemorrhage. Allen of Philadelphia in 1869 was the first in this coun- 
try to treat a case of extra-uterine (abdominal) pregnancy by this method 
with success. He was followed by Landis, McBurney, Thomas, Lusk, 
Bache Emmet, Munde, Wilson, Janvrin, Garrigues, and a number of 
others, one of the last of whom, A. Brothers of New York, collected all 
the reported cases and published them in an excellent paper printed 
in the Am. Journal of Obstetrics for May, 1888. Of the 43 cases in 



778 EXTRA-UTERINE PREGNANCY. 

Brothers' list, 2 were treated by electro-puncture, 21 by faradism, 16 
by galvanism, 2 by both currents, and 1 by franklinism ; 1 case is 
unclassified. Only 1 case terminated fatally, that of Janvrin, in which 
the electricity was employed too late, rupture of an artery in the sac- 
wall having occurred nine days previously. Therefore, neither in this nor 
Hicks' s case can the death really be attributed to the electricity. In 
none of the cases, so far as could be learned, did suppuration of the 
ovisac occur after the foetus was killed by the electric current, but the 
sac gradually shrivelled and gave rise to no further disturbance. 

The one great objection to this treatment of ectopic gestation in the 
early months (up to four months) is the uncertainty of diagnosis. Some 
extreme authors even go so far as to assert that the diagnosis of an 
unruptured tubal pregnancy in the early months has never been made. 
This is manifestly incorrect, and does not merit discussion. Lapa- 
rotomy specialists favor that operation in all cases of tubal preg- 
nancy when the ovisac and its contents can be entirely removed. 
Of course the electric current (preferably the faradic) is applicable only 
to cases where absolutely no sign of impending rupture is present. One 
pole is placed against the dilated tube, either in the vagina or rectum, 
and a series of sharp shocks are passed through, several sittings being 
given until the sac ceases growing. 

2. Puncture and Injection of the Sac. — This method has now been 
entirely abandoned, although it was performed in a number of instances 
with good results — viz. twice by Morton, and once each by Greenhalgh, 
Stoltz, and Koeberle. [I have resorted to this plan twice, and lost 
both patients. One died of septicaemia, the other of hemorrhage into 
the sac and rupture. Dr. Routh has reported a case which ended 
fatally after the same operation as my second one did. — T. G. T.] 

3. Aspiration of the Amniotic Fluid has now also given way to the 
more certain and less dangerous methods of electricity and laparotomy. 

(b) The pregnancy being to all appearances one of the tubal variety, 
and immediate action being demanded by severity of symptoms, the 
operation of laparotomy should at once be performed, the broad and 
ovarian ligaments and the Fallopian tube be included as a pedicle in a 
ligature, and the whole mass be removed. 

The one great danger to be feared from the growth of a tubal or 
interstitial pregnancy is the rupture of the tube or uterine horn, and a 
violent hemorrhage into the peritoneal cavity, which may at once prove 
fatal, or, recurring once or oftener, speedily carry off the patient. The 
signs of impending rupture are paroxysmal attacks of pain of a dart- 
ing, tearing nature in one or the other ovarian region, followed by tem- 
porary nausea and faintness. At what period in the gestation the 
rupture may happen can never be foreseen, since it has occurred 
at as early a period as four weeks after impregnation, and has been 
deferred in a few rare instances to the fourth and fifth months. The 
usual period at which the tube gives way is between the sixth and tenth 
weeks. If there is the slightest suspicion of the existence of a tubal 
pregnancy, based on both rational and physical signs, we should on no 
account wait until symptoms of impending rupture have made their 
appearance, or indeed until that accident has actually occurred, which 



TREATMENT. 779 

is liable to be the case at any time, day or night. But Ave should at 
once proceed to arrest the growth of the ovum by electricity if we hap- 
pen to be a believer in that practice, or remove the ovisac and its con- 
tents by laparotomy if we doubt the efficacy of the electrical treatment. 
The opening of the ovisac with the Paquelin knife, which we formerly 
practised and recommended, has now been abandoned by us in favor 
of the above methods. 

(c) Should the pregnancy unquestionably be abdominal, as proved 
by its advance beyond the period ordinarily possible for tubal disten- 
sion, and by the comparatively small size of the uterus, it should not 
be interfered with until the completion of the full term. At that time 
an effort at labor usually occurs and gives a signal for action. Should 
this most fortunate event occur, the crowning triumph of obstetric sur- 
gery may be reached in the delivery of a living child from a living 
■woman at full term, as was first done by Jessop of Leeds in a case 
reported to the London Obstetrical Society a few years ago, and has 
since been accomplished by Breisky, Eastman, Braun, Tait (3 opera- 
tions, 3 children, and 2 mothers living), and others. According to sta- 
tistics of Harris {Am. Journ. Med. Sci., Sept., 1888) of 30 cases of 
primary laparotomy with living foetus near term, up to 1880 there 
were 20 cases, with but 1 success for the mother and 10 for the child. 
From 1880 to 1888, however, there were 10 cases with 4 recoveries of 
the mother and 6 of the child ; hence with increasing experience and 
dexterity the results are visibly improving in this formerly almost des- 
perate operation. 

In those cases where the head passes downward into the pelvis it 
sometimes becomes possible to cut through the vaginal wall, seize the 
presenting part by the obstetric forceps, and deliver a living child from 
a woman, only slightly endangered by the operation, almost per vias 
naturales. In the year 1816, Dr. John King, a country practitioner 
residing upon Edisto Island, on the coast of South Carolina, met with 
just such a case as we have pictured, and, being both a bold and orig- 
inal man, he followed the course to which we have alluded, with the 
result of saving mother and child. This case will be found published 
in the Med. Repository, 1817. 

(d) Should delivery at full term not be accomplished, a lithopiedion 
or petrified infant may result and be retained for many years ; suppura- 
tive action may occur in the foetal envelopes, and laparotomy be subse- 
quently resorted to as a secondary operation ; or, the liquor amnii 
being absorbed, the bones of the child may remain clasped by the foetal 
envelopes and produce dangerous inflammation and ulceration. Under 
these circumstances it requires a great deal of consideration as to the 
proper course to pursue, whether to interfere or to leave matters to 
nature. Even if it be recognized that interference will surely become 
necessary, the question arises as to the time at which it should be prac- 
tised. In the other varieties of extra-uterine pregnancy the continued 
progress of gestation exposes the woman to constant and steadily increas- 
ing danger of sudden death. In the abdominal form it not only does 
not do this, but it is, as has been stated, often the wise course to allow 
the process to continue until the child arrives at full development. 



780 EXTRA-UTERINE PREGNANCY. 

Let us suppose that either before or after full term of gestation the 
child has died, and it is pretty certain that the woman carries her dead 
offspring within the peritoneal cavity. Is it wise on this account at 
once to interfere by surgical means ? We think not. One of the great- 
est dangers attaching to interference consists in hemorrhage. The long- 
er time that the placenta remains attached after foetal death the more 
certain is it to become atrophied and consequently less vascular. An- 
other great danger consists in septicaemia. The more thoroughly the 
foetal envelopes become disgorged and atrophic from loss of function, 
the less likely is this dangerous complication to develop. Judicious 
delay and cautious waiting for symptoms indicative of approaching 
trouble are, then, in my opinion, decidedly advisable. 

But such delay, such waiting, are by no means to be carried so far 
that symptoms of septic absorption shall occur. Non-interference car- 
ried as far as this is not less to be deprecated than a rashness which 
results in intemperate and premature resort to operation. 

A foetus remaining in the abdominal cavity long after the full term 
of gestation having lost its life, and being surrounded by intestines 
after absorption of the liquor amnii or by a purulent fluid which has 
replaced it, is always an element of great danger which must become 
more and more aggravated as time passes. Its removal should be 
regarded only as a question of time, not of propriety. It is true that 
instances are on record where such contents have remained in the 
bodies of unfortunate women for thirty and forty years, but such cases 
are rare exceptions to the rule, and the impropriety of leaving these 
women for the remainder of their lives in such peril could be tolerated 
only in the dark days of abdominal surgery. 

[I have operated six times for extra-uterine pregnancy, but never have 
I done so without good reason for believing that delay would be far more 
dangerous than immediate interference. Out of the six operations, four have 
saved lives which were in imminent peril. Nevertheless, I am willing to 
accept as a rule the precept that operative procedure in the abdominal form 
of extra-uterine pregnancy had better, if possible, be delayed until Nature 
points to the channel of extrusion which she selects. The most dangerous 
of men, however, are those who implicitly, unthinkingly, obey rules. The 
bold and wise surgeon is he who keeps the rule for general guidance, break- 
ing it unhesitatingly when an exceptional indication demands such a course. 
— T. G. T.] 

No fixed rule can apply to all these cases. The following may 
guide the practitioner in general, he modifying them to suit the vary- 
ing indications which may present themselves : 

Before full term, should the child developing in the peritoneal cav- 
ity be alive, its growth may be carefully watched, and the end of the 
ninth month be waited for in hope of delivering at that time, either by 
laparotomy or elytrotomy, a living child from a living woman. 

Should the child have died early in the pregnancy, delay in inter- 
ference is advisable, but this should not be carried to the development 
of septicaemia, either acute or chronic. 

Should the full term be passed and the child be still imprisoned in 



TREATMENT. 781 

its unnatural resting-place, the rule should be to wait for evidences of 
constitutional disorder on the one hand, and to meet its development 
promptly and decisively by succor on the other. 

The most favorable condition for laparotomy is when the foetal sac 
is adherent to the abdominal walls, and opening into the peritoneal 
cavity becomes unnecessary. When the sac is not thus adherent, its 
walls should be stitched to those of the abdomen, the peritoneum be 
shut off, and antiseptic injections practised. 

If the pregnancy be interstitial, the uterine cavity should be dilated, 
so that palpation from within it can be practised and the possibility 
of incision considered. 

We have already indicated the course to be pursued when the 
rupture of the sac of an interstitial or tubal pregnancy is imminent 
or has already taken place. In either case the only wise and safe 
course is to open the abdominal cavity as rapidly as possible and 
remove the rupturing or already ruptured tube, securely ligating its 
uterine attachment. The abdominal cavity should then be thoroughly 
cleansed of coagula by means of warm boiled water or Thiersch's solu- 
tion poured into it from a pitcher, Douglas's pouch be carefully sponged, 
and the wound closed with or without a drainage-tube as the judgment 
of the operator may decide. At the present day the indications for 
this procedure are so clear and universally accepted that no serious 
objection can be made to them ; but this was not always the case. It 
is only within the last few years that the profession has agreed to accept 
this view of the matter. The credit for first advocating this bold and 
radical policy is due to Dr. Stephen Rogers of this city, who in 1867 
wrote a monograph strongly recommending laparotomy in these cases 
for the control of hemorrhage. The only objections to this practice are 
— first, the difficulty of making the diagnosis ; and, second, the late hour 
at which the operator is frequently called to such cases. As regards 
the first objection, the symptoms of severe intra-peritoneal hemorrhage, 
whether they are due to a ruptured tubal pregnancy or to the rupture 
of some other intra-abdominal vessel from another cause, should call 
for the exercise of the universally accepted surgical principle — namely, 
in case of hemorrhage to expose the bleeding vessel and to ligate it. 
Therefore, no matter whether the hemorrhage was due to a ruptured 
tube or to the rupture of some other vessel, laparotomy should be at 
once performed and the bleeding spot brought to view and permanently 
secured. It is safe to say, however, that in by far the large majority 
of sudden intra-peritoneal hemorrhages the cause is the rupture of 
a gravid tube. As regards the second objection, it undoubtedly holds 
good in a number of cases, but instances have been reported where 
women who were absolutely pulseless and apparently in articulo mortis 
have rallied after laparotomy and ligation of the ruptured tube, and 
have made a perfectly smooth recovery ; therefore, no case should be 
pronounced too far gone for operation in which even the slightest 
evidence of life persists. 

[In the last edition of this work I stated that in my personal experience 
of seventeen cases, I had seen but one in which I could have been justified 
to perform laparotomy for hemorrhage from a ruptured pregnant tube. In 



782 DISEASES OF THE UTERINE LIGAMENTS. 

that case a lady bled steadily for over forty-eight hours, and although I 
urged the diagnosis of tubal pregnancy and the propriety of laparotomy very 
strongly, I was overruled as to both points by a strong consultation. A 
post-mortem examination showed a foetus near the fimbriated extremity of 
one tube surrounded by its liquor amnii. The sac was not ruptured, but one 
vessel on its circumference was, and from this a fatal flow had occurred. 
Laparotomy would almost surely have saved the life of this patient. Since 
then I have come to believe that the possibilities of laparotomy are very 
much greater in these apparently desperate cases than was formerly my 
opinion.— T. G. T.] 



CHAPTEB XLVIII. 

DISEASES OF THE UTERINE LIGAMENTS. 

The uterine ligaments are eight in number — two broad, two round, 
two utero-vesical, and two utero-recto-sacral. All of these but the 
round ligaments are composed of folds of peritoneum containing scat- 
tered throughout them irregular layers of smooth muscular fibre. They 
support the uterus from above, prevent it from sinking too low or 
remaining below its normal altitude in the pelvic cavity, or from 
assuming either a permanent anterior, posterior, or lateral deviation. 
As supporters of the uterus they are of the greatest importance, their 
relaxation resulting in a displacement of that organ in one of the 
directions mentioned, even though the vaginal walls, peritoneum, and 
pelvic fascia be intact. 

Diseases of the Broad Ligaments. 

Anatomy. — Firmly enclosing the fundus and body of the uterus 
down to the level of the internal os is the peritoneal membrane. 
Anteriorly in the median line the peritoneum ascends over the fundus 
of the bladder and is extended upon the anterior abdominal wall. 
Posteriorly the peritoneum descends very much deeper, in fact down 
to the roof of the vagina, then passes up on the anterior wall of the 
rectum, being thrown on either side of the rectum into two sharp folds 
— the utero-recto-sacral ligaments. Laterally the peritoneum covers 
the pelvic walls and passes upward into the iliac fossa to join the 
anterior portion of the membrane on the one hand, and posteriorly to 
cover the posterior aspect of the abdominal cavity. That portion of 
the anterior and posterior folds of the peritoneum which extends from 
the fundus uteri to the ilio-pectineal line is called the broad ligament ; 
in its upper edge runs the Fallopian tube ; situated between the two 
layers, and projecting uncovered by peritoneum through the posterior 
layer, is the ovary. Situated also between its two layers is an embry- 
onal body consisting of a number of small tubes and cysts, a probable 
remnant of the Wolffian body, the so-called parovarium or organ of 
Rosenmiiller. The connection between the peritoneum and the body 
of the uterus is exceedingly firm, but otherwise the layers of the broad 



DISEASES OF THE BROAD LIGAMENTS. 783 

ligament are separated by a fair amount of cellular tissue, in conse- 
quence of which the peritoneum may be pushed away from its attach- 
ment, and pressed upward and inward by tumors which develop between 
the folds of the broad ligament (intraligamentous ovarian and fibroid 

Fig. 330. 



Parovarium, or Organ of Rosenmuller. 
a, b, c, d, f, parovarium ; e, broad ligament ; h h, tube ; i, cyst of Morgagni ; /, ovary. 

tumors, cysts of the broad ligament) or by plastic exudations, effusions 
of blood, or purulent accumulations. We have seen the peritoneum 
thus dissected up almost to the region of the kidney, and it is easily 
understood how extra-peritoneal — that is, intraligamentous — effusions 
of lymph, blood, or pus may make room for themselves by separating 
the peritoneum from the pelvic wall, and present on the anterior 
abdominal wall even as high as the antero-superior spinous process of 
the ilium. Fibrous tumors of the uterus, ovarian tumors, and cysts of 
the broad ligaments which have developed in a similar manner have 
been known to push up the peritoneum so far as to become chiefly 
abdominal, all the time of course being retro-peritoneal. 1 

Tumors of the Broad Ligament. — The chief form in which 
tumors of the broad ligament present themselves is as cysts, which 
develop from the parovarium just referred to, and grow down between 
the layers of the broad ligament. These cysts usually grow more 
slowly than ovarian cysts, have a tendency to point downward into the 
pelvic cavity at first, and only to encroach upon the abdominal cavity 
as they grow larger. They also do not interfere with the general 
health of the patient as do ovarian tumors, and give rise to very little 
discomfort except through the pressure which they may exert on the 
pelvic organs by their increasing growth. These cysts are always 
monocysts. 

Diagnosis. — The diagnosis will be made chiefly by the slow growth. 
the absence of cachexia, the deep seat in the pelvis of the tumor, the ab- 
sence of solid material ; by the fact that the cyst usually does not exceed 

1 See plate facing i>. 473. 

50 



784 DISEASES OF THE UTERINE LIGAMENTS. 

in size that of a pregnant uterus at six months ; and finally, by the 
entirely transparent, limpid character of the fluid removed by the aspi- 
rator, which under the microscope shows nothing but a few ciliated 
epithelia, but no granular matter or corpuscles whatever. Occasionally 
these cysts grow very large, and one was operated on by Munde which 
contained thirty-eight pints of fluid. 

Prognosis. — As a rule, unless they should happen to become trouble- 
some on account of their unusual size, these cysts of the broad ligament 
are not productive of any particular danger or discomfort to the patient. 
Still, as they produce an abdominal enlargement, as the diagnosis is not 
always certain, and as even after tapping they are liable to refill, at the 
present day they are usually operated upon precisely as though they 
were ordinary ovarian cysts. 

Treatment. — Formerly, when the diagnosis of a cyst of the broad 
ligament was made, it was thought the proper thing to empty it by 
paracentesis, and to trust to nature that it would not refill. This 
expectation undoubtedly often came true, but quite as often the reverse 
was the case, and after repeated tappings it was finally found necessary 
to remove the cyst. This is usually not very difficult or dangerous, 
except in one particular — namely, that the cyst, being developed 
between the layers of the broad ligament, has no pedicle, and in this 
respect resembles intraligamentous cysts of the ovary, which, it will 
be remembered, we pronounced to be among the most difficult for ope- 
ration of all tumors of that organ. If the sac of the parovarian cyst 
can be enucleated, this should be done, and the cavity remaining may 
then be closed by deep catgut sutures so introduced as to thoroughly 
approximate its walls. The broad ligament is then dropped and the 
abdominal wound closed. A safer plan, and one which we have usually 
adopted, is — either after enucleating the cyst, or, if this was not possible, 
without enucleating it — to remove the excess of the sac, including broad 
ligament and cyst-wall, and sew the remainder with the interrupted suture 
into the abdominal wound. The sac was then packed with iodoform 
gauze and allowed to heal by granulation, as already described under 
Intraligamentous Cysts of the Ovary. We have performed many such 
operations, and do not remember ever losing a case. 

Solid Tumors of the Broad Ligament. — These are usually 
fibroid tumors of the uterus which have grown from the lateral wall of that 
organ and developed between the layers of the broad ligament, pushing 
them before them, as already described. This peculiar direction of 
fibroids of the uterus is fortunately rare. The diagnosis can be made 
only by the position of the tumor, and if it has grown so large as to 
warrant its removal by laparotomy, the true relations of the growth 
will often be recognized only after the abdominal cavity has been 
opened. The operative removal by laparotomy is rendered exceedingly 
difficult in consequence of the necessity of splitting the covering of the 
tumor — which, be it understood, is the broad ligament — and peeling the 
tumor bodily out of its bed, during which manoeuvre very severe and 
not easily to be arrested hemorrhage may take place. Usually the sac 
enclosing the growth is to be sewed to the abdominal incision and 
packed with iodoform gauze, as already mentioned. Occasionally such 



DISEASES OF THE BOUND LIGAMENTS. 785 

intraligamentous tumors of the uterus may be susceptible of removal 
through the vaginal vault. 

Effusions of plastic lymph, of blood, and accumulations of pus 
between the layers of the broad ligament have already been sufficiently 
described under the respective heads of Pelvic Cellulitis, Pelvic Hema- 
toma, and Pelvic Abscess, to which chapters the reader is referred. 

Diseases of the Utero-vesical and Utero-recto-sacral Ligaments. 

The diseases chiefly affecting these two sets of ligaments are relax- 
ation and contraction. The relaxation is due to the stretching pro- 
duced by a subinvolution following successive pregnancies and child- 
births. The contractions result from peritonitis, usually of the pelvic 
variety, and frequently entirely unsuspected by the patient. The retro- 
uterine ligaments are more frequently affected by inflammatory contrac- 
tions than the ante-uterine, and the cervix is very often found drawn 
backward and attached more or less immovably to the anterior surface 
of the rectum. It should be added that inflammatory contraction of 
the broad ligaments may also take place and cause fixation of the cer- 
vix toward one side or the other, with a corresponding inclination of 
the fundus in the opposite direction. 

The diagnosis of these conditions is very easily made, since in relax- 
ation of the ligaments the uterus becomes abnormally movable, and 
sinks with equal facility in every direction toward which either the 
finger or the position of the patient induces it to fall, and in contrac- 
tion the normal mobility of the organ is more or less limited accord- 
ing to the ligament which is shortened and the amount of its contraction. 

Treatment. — For relaxation of the uterine ligaments very little can 
be done : support from below by means of astringent vaginal tampons 
until involution has taken place if the case be one of recent parturition; 
the faradic current applied directly to the relaxed ligaments; massage 
of the uterus and its adnexa as recently advocated by Thure Brandt, 
Schultz, Profanter, and others ; and possibly ventro-fixation as a radi- 
cal measure, — are the chief means of treatment. For contracted liga- 
ments the systematic firm tamponing of the vagina with absorbent cot- 
ton, or, what is better, prepared sheep's wool, in order to gradually 
effect a dilatation of the vaginal vault, and thereby a stretching of the 
contracted ligaments; frequent massage and manipulation of the uterus 
so as to stretch the ligaments; and perhaps carefully selected pessaries. — 
may eventually produce the desired result. 

Diseases of the Round Ligaments. 

There are but few diseased conditions of the round ligaments to be 
mentioned. Duncan, Kleinwachter, and Winckel report each a ease 
of intra-peritoneal fibro-myoma of the round ligament. Hydrocele oIl 
the ligament has also been observed, which is a defect of development. 
Adhesion of the round ligament to the canal of Nuck is not uncommon, 
and forms a decided obstacle to the success of Alexander's operation 
for shortening the ligament in retro-displacement of the uterus. Length- 



786 STERILITY. 

ening and relaxation of the round ligaments is commonly observed as a 
result of backward displacement of the uterus, and is not in itself a 
disease. 

The treatment of these few morbid conditions of the round ligaments 
is as simple as the disease. A tumor, if it gives rise to symptoms, 
should be removed, likewise a hydrocele, or at least freely incised and 
allowed to granulate. Relaxation of the round ligaments is treated by 
opening the canal and drawing them out and cutting oif the excess ; 
the remainder is sewed into the canal. This operation, however, is 
never performed except for the indication of permanently replacing a 
retro-displaced uterus. 



CHAPTER XLIX. 
STERILITY. 

Definition and Synonyms. — This term, which is derived from azspsoz, 
"barren," and implies an incapacity for conception, is synonymously 
entitled barrenness and infecundity. 

History. — Throughout medical literature, from the earliest periods 
to the present, it has attracted special attention, and been the subject 
of dissertations by all authors who have touched upon the affections 
peculiar to females. The frequent reference made to it by biblical 
writers as a reproach to women is too well known to require special 
mention. 

Causes. — To comprehend the pathology of sterility the physiology 
of conception must be clearly understood. In the act of coition the 
male organ, being introduced into the vagina, projects into and against 
the cervix a fluid consisting of a thick, watery portion holding in sus- 
pension large numbers of ciliated cells which have power of moving by 
ciliary action. The bulk of this fluid pours down into the vagina, but 
many of the cells which it contains pass upward into the body of the ute- 
rus and through the Fallopian tubes as far as the ovaries. Should they 
come in contact with an ovule, impregnation may take place in the ova- 
ries, Fallopian tubes, or uterus. When the impregnated ovule attaches 
itself to the uterus, the mucous membrane of this organ undergoes 
exuberant development and throws around it an envelope called the 
decidua reflexa. Further than this the process does not concern us, 
for conception has then followed impregnation, fixation of the impreg- 
nated ovum having occurred. 

These facts being kept in mind, it becomes evident that a variety 
of influences may interfere with the performance of this delicate and 
subtle process. For its accomplishment four things are necessary as 
far as the woman is concerned — 

1st. The possibility of the entrance of seminal fluid into the uterus ; 

2d. The possibility of the production of a healthy ovule ; 



CA USES. 787 

3d. The possibility of the entrance of an ovule into the uterus ; 
4th. The absence of influences in utero destructive to the vitality of 
the semen and preventive of fixation of the ovum upon the uterine wall. 
Should these four conditions exist, no woman will be sterile. She 
may not bear children, but the incapacity may attach to the male, and 
not to her ; or, having conceived, she may have suffered from consecu- 
tive abortions, which have been mistaken for attacks of menorrhagia. 

The special causes of sterility, or those interfering with these con- 
ditions, may be thus presented : 

1st. Causes 'preventing entrance of semen into the uterus : 
Absence of the uterus or vagina ; 
Obturator hymen ; 
Vaginismus ; 
Atresia vaginae ; 
Occlusion of cervical canal ; 
Conical shape of cervix ; 
Cervical endometritis ; 
Polypi or fibroids ; 
Displacements ; 

Very small os internum or externum. 
2d. Causes preventing the production of a healthy ovule : 
Chronic ovaritis ; 
Cystic disease of both ovaries ; 
Cellulitis or peritonitis ; 
Absence of ovaries. 
3d. Causes preventing passage of ovule into the uterus : 
Stricture or obliteration of Fallopian tubes ; 
Absence of Fallopian tubes ; 

Detachments and displacements of Fallopian tubes. 
4th. Causes destroying vitality of semen or preventing fixation of 
impregnated ovum : 
Corporeal or cervical endometritis ; 
Membranous dysmenorrhea ; 
Menorrhagia or metrorrhagia ; 
Abnormal growths ; 
Areolar hyperplasia. 
5th. Causes producing non-retention of semen in the vagina : 
Laceration of perineum ; 
Rectocele ; 

Prolapsus uteri et vaginae. 
The mode of action of most of these causes is so self-evident as to 
make anything more than their mention unnecessary. Some of them, 
however, require special explanation. 

Vaginismus is an appellation which has been given of late years to 
a hypemesthetic state of the ostium vaginae which results in spasm o\' 
its sphincter. This interferes with the "entrance of the male organ, and 
consequently of seminal fluid into the vaginal canal : indeed, in aggra- 
vated cases it entirely precludes sexual approaches. The affection is 
by no means rare, and is a fruitful source of sterility. 

An abnormal shape of the cervix has been pointed out by Dr. Sims 



788 



STERILITY. 



Fig. 331. 




Anteflexion of Cervix. 



as a frequent cause of infecundity. If this part be too long, so as to 
curl or bend upon itself, it is evident that it may not admit seminal 

fluid through its canal. But even 
a slighter degree of elongation, in 
which the cervix has a conical 
shape, has been observed to be 
frequently followed by that con- 
dition. 

Endometritis, whether it be cer- 
vical or corporeal, fills the uterine 
canal Avith a thick, tenacious mucus 
which often prevents the entrance of 
seminal fluid or destroys its vitality. 
Flexions of the uterus, by pro- 
ducing bending of the cervical canal, 
and versions, by pressing the os 
against one wall of the vagina so 
as to close it as if by a valve, may 
entirely obstruct the passage to the 
uterus. 

Obliteration and displacement 
of the tubes frequently result from 
pelvic peritonitis, and thus that affection often entails sterility of the 
most irremediable character. (See the various illustrations of tubal dis- 
ease in the chapter on that subject.) The 
second stage of the disease consists in ef- 
fusion of lymph, which in time undergoes 
contraction and either closes these canals 
or draws them out of place. 

Membranous dysmenorrhea, or rather 
the tendency to exfoliation of uterine 
mucous membrane which characterizes it, 
so alters the uterine surface as to render 
it inapt for the fixation of the ovum. 

Menorrhagia and metrorrhagia may re- 
sult in the washing away of the ovum after 
impregnation and before fixation. The 
normal menstrual hemorrhage occurs be- 
fore the entrance of the ovule into the ute- 
rus. If it be excessive and prolonged, it 
may remove the ovule entirely, and in the 
same way metrorrhagia may remove the 
impregnated ovum. An abortion does 
not occur under these circumstances, for, 
although impregnation may have taken 
place, conception has not done so. 

Abnormal growths of any form which fill the uterine cavity — as, for 
example, fibroids, polypi, hydatids, or moles — may so interfere with the 
attachment of the ovum to the uterus as to prevent conception even 
when impregnation has occurred. 



Fig. 




Extreme Degree of Anteversion 
(Beigel). 



CA USES. 



789 



Laceration of the perineum of the deeper degrees, with or without 
prolapse of the posterior vaginal wall and uterus, may, by permitting 
the semen to flow out of the vagina immediately on the withdrawal of 
the male organ, or when the woman sits or stands up, be a cause of 
sterility. 

Although it is impossible to give positive proof of the fact that serious 
chronic disease of the ovaries results in a blighting influence upon the 
ovule, such a conclusion is rendered highly probable by the results of 
experience in such cases. Such a result is often found to attend chronic 
oophoritis, general pelvic peritonitis or cellulitis, and double cystic dis- 
ease of the ovaries. 

Some of the causes here enumerated are much more frequent than 
others. We would enumerate the most common causes in the order of 

their frequency in the following se- 
quence : First, glandular cervical en- 
dometritis ; second, areolar hyper- 
plasia, the result of subinvolution of 
the uterus ; third, conoid cervix, with 
contracted os ; fourth, flexion and ver- 



Fig. 333. 




sionof the uterus 



fifth, contraction of 



Fig. 334. 



:1i ; lllfe&lfc*. 



Vulva of Multipara. Rectocele, with gaping Vaginal Orifice. 

Showing; possible non-retention of semen as a frequent cause of sterility. 

os externum ; sixth, fibroids, interstitial or submucous : seventh, monor- 
rhagia or metrorrhagia : eighth, ovarian incapacity from chronic oophor- 
itis or pelvic peritonitis; and, ninth, non-retention of semen. We do 
not state this sequence dogmatically, but merely to convey an idea of 
our impressions with reference to the matter. 



790 



STERILITY. 
Fig. 335. 




Fig. 336. 



Mucous Polypus occluding Right Tubal Opening (Beigel). 
B, wall of uterus; C, orifice of right tube; D, orifice of left tube ; A, mucous polypus. 

Differentiation. — Before it is determined that a woman is sterile the 
sexual capacity of the husband should be ascertained. Men are averse 

to the confession of impotence, and 
will often allow the supposition of 
sterility on the part of their wives to 
be maintained rather than admit the 
truth. In two cases we have used an 
anaesthetic, ruptured the hymen, and 
distended the vagina, under the impres- 
sion that sterility of several years' 
standing was due to the impossibility 
of the accomplishment of intercourse, 
and in two other cases have dilated the 
uterus, curetted for endometritis, and 
caused an intra-uterine stem to be worn 
for a number of months, under the 
impression that the canal was too nar- 
row and bent for conception ; and in 
all these four cases have subsequently 
discovered that the husbands of our patients were entirely impotent, 
and had been so before marriage. 

Gross has found that in about 8 per cent, of all cases of sterility 
the fault lay with the husband, who might be apparently perfectly 
potent, with abundant seminal discharge, but whose semen proved under 
the microscope to be entirely void of spermatozoa or to show only a 
few feeble or dead ones. 




Retroposed and Anteflexed Uterus (a 
frequent cause of sterility). 



PROGNOSIS— RESULTS. 791 

Prognosis. — In reference to a disorder which may be produced by 
such a variety of causes no positive prognosis can be given, for its cure 
will entirely depend upon the removal of the agency which produces it. 
Much, too, will depend upon the thorough investigation of the causes 
by the physician, and a proper understanding on his part of the treat- 
ment. Unquestionably, a large proportion of sterile women may by 
appropriate treatment be made fruitful. 

In this connection it may seem appropriate to make a few remarks 
on two causes of sterility which we have not thought best to incorporate 
in the systematic list given on page 787. 

We have frequently seen women with no apparent reason for their 
sterility, so far as an examination of their sexual organs could deter- 
mine, but who were anaemic, adipose, flabby, phlegmatic, and confessed 
to an entire absence of sexual desire or gratification. It has seemed 
to us that in these women there was a constitutional reason for their 
failure to conceive, and that by increasing the amount of red blood- 
corpuscles in their blood, by reducing their adipose through the admin- 
istration of iron, exercise, massage, Turkish baths, and perhaps a course 
of treatment at Marienbad or some similar resort, their sexual activity 
would be so stimulated that conception might result ; and we have seen 
too many successful cases after this plan of treatment not to believe 
that the result was, to a certain extent at least, due to the treatment. 
Again, we have found a change of air and scenery, such as is produced 
by a trip abroad, to bring on in some way a change of nutrition and 
an activity of the sexual organs which resulted in a speedy impreg- 
nation. 

The second cause for sterility, which we advance with some hesita- 
tion, is a possible lack of affinity between husband and w r ife. We do 
not mean to imply that such affinity, or even affection, must necessarily 
be present in order to ensure the occurrence of conception, for we know 
that many women readily conceive who have no special affection for 
their husbands nor desire for offspring, nor even sexual passion what- 
ever ; but it is an undoubted fact that some women will not bear 
children by certain men, who have had children by other women, and 
have since been perfectly healthy, whereas in a second marriage con- 
ception readily takes place. 

Of course, while the treatment of the first-named cause is self-evi- 
dent and easy to carry out, for the latter we as physicians can do nothing. 

The suggestion made and carried out in several instances by Sims. 
to produce conception artifically by injecting the semen into the uterus 
— "artificial impregnation" — has been followed by Courty. Pajot, 
Eustache, Hegar and Kaltenbach, Munde, and others, but has been so 
uniformly unsuccessful that it may be said to have been practically 
abandoned. 

Results. — No physical results are produced by sterility, but its 
existence will frequently depress the spirits and sadden a disposition 
which under other circumstances would have been cheerful and equable. 
The married woman has always regarded, and will for ever view, this 
incapacity as a reproach to her womanhood, and no amount of argu- 
ment can make her accept it with resignation. 



792 



STERILITY. 



Fig. 337. 




Fig. 338. 



Anteflexion of the Uterus, showing Sims's posterior discission. 

Treatment. — The treatment of sterility consists in the removal of 
its cause. Many of these causes are not susceptible of remedy, while 

the means of treating others are 
so evident that special mention 
may be confined to a feAV. Obtu- 
rator hymen, vaginismus, atresia 
vaginae, and occlusion of the cer- 
vical canal should be treated by 
the surgical operations appropriate 
to each. 

In case the vaginal cervix 
should, to only a limited extent, 
be too projecting or conical, the 
bilateral operation for its enlarge- 
ment should be practised after the 
method elsewhere described. If a 
slight constriction of the cervical 
canal appear to be the cause of the 
condition, dilatation may be es- 
sayed in place of ^ surgical pro- 
cedure. In an aggravated case, 
when the neck projects markedly 
and is decidedly conoidal in shape, 
both these means are insufficient ; 
amputation then becomes neces- 
sary. After this has been recov- 
ered from, the bilateral operation for cervical hysterotomy is often ne- 




Excision of Projecting Lip of Cervix. 



TREATMENT. 793 

cessary before cure is effected. In this connection the chapters upon 
Cervical Endometritis and Dysmenorrhoea should be referred to. 
Endometritis should be appropriately treated, and abnormal growths 
should be dealt with as if sterility did not exist. 

If a displacement be discovered and replacement and retention be 
possible, they should be practised. But if in case of flexion this be 
impossible, the uterine canal should be rendered as straight as is prac- 
ticable by the cervical incision recommended by Dr. Sims for dysmen- 
orrhoea. Menorrhagia and metrorrhagia should be treated upon the 
plan recommended in the chapter upon those subjects, and the patient 
be advised to keep very quiet and to avoid warm and stimulating bev- 
erages during menstrual epochs. 

If the conditions seem to warrant the correctness of the inference 
that sterility is due to the non-retention of the semen, the lacerated 
perineum should be restored and the rectocele cured by the appropriate 
operations. In any case, the advice should be given to practise coition 
with the woman's pelvis elevated by a cushion or pillow, this position to 
be maintained during the remainder of the night. Coition a posteriori 
has also been recommended in cases where no tangible cause for the 
sterility could be discovered. 

As we have elsewhere stated, glandular endometritis and tortuosities 
of the uterine neck are among the most frequent of the causes of 
sterility. The first of these is a disorder which is often incurable, and 
the surgical operations practised for the latter very commonly fail of 
result. And so w T ith regard to other conditions resulting in sterility. 
If at the end of a large experience every one would compare the num- 
ber of his failures in treating sterility with that of his successes, his 
results would not be regarded as very satisfactory. Unfortunately, the 
unsuccessful cases soon sink beneath the mental horizon, while the 
successful ones stand out prominently, and thus many a practitioner by 
his evidence unintentionally misleads others and produces disappoint- 
ment. 

In closing this chapter we feel constrained to say that, fully impressed 
as we are by the mechanical theory of the production of sterility as 
first ably advanced and described by J. Marion Sims, we would not 
consider that we are doing our duty by our patients if we fail to give 
them the benefit of all the means which are at our disposal for the 
relief of whatever mechanical obstructions we may find ; and therefore, 
no matter how small the number of successes which we may attain by 
such treatment, we should always advise and practise it, provided it can 
be carried out without special risk or injury to the patient. One suc- 
cessful result out of a hundred failures will still repay us for our labors, 
and one grateful woman will to a certain extent compensate for the 
other ninety-nine, who at all events are no worse off than they were 
before. 



794 



DISEASES OF THE FEMALE MAMMARY GLANDS. 



CHAPTER L. 



DISEASES OF THE FEMALE MAMMARY GLANDS. 



Although it is not customary to treat of the diseases of the female 
breast in systematic textbooks on the diseases of the female sexual 
organs, the general surgeon having taken possession of that field, we 
have thought best to close the revision of this work with a chapter on 
this subject. The female breast is, after all, a part of the sexual appa- 
ratus, and its diseases should be known to and treated by the gyne- 
cologist. It is not, however, our intention to go into very minute details 
on any point, but merely to give a superficial sketch of the malformations 
and diseases to which the female mamma is liable, referring the reader to 
the works of Billroth, Gross, and others for a complete description. 

The malformations of the female mamma may be either entire 
absence, rudimentary or supernumerary development, and absence or 
retraction of the nipple. The diseases of the breast may be either 
acute or chronic. Of the acute diseases, the most common is inflam- 



Fig. 339. 



Fig. 340. 





A case of Polymastia with ten thoracic milk- 
secreting nipples (Neugebauer). 1 



Case of Polymastia, from the work 
entitled Fortunius Licetus de Monstris, 
Patavii, 1668. (Taken from La Torre, 
op. cit.) 



mation of the gland, following parturition or puerperal mastitis ; fissure 
or excoriation of the nipple usually precedes the inflammation of the 
gland itself. Of the chronic affections, tumors of the glands constitute 
by far the largest proportion. These may be either benign (hyper- 
trophy, fibroma, lipoma, adenoma, cysto-adenoma, and cysts) or malig- 
nant (sarcoma, cysto-sarcoma, and carcinoma). We will now proceed 
to treat of these different varieties separately. 

Absence of the mammary gland in the female (amazia) is of rare 
occurrence. In one case seen by Louisier it was hereditary ; in Fro- 

1 From La Torre, B mio primo anuo di Pratico Obstetrico-Gynecologico a Roma, 1891. 



SUPERNUMERARY MAMMJE. 



795 



riep's and Schloezer's cases there was likewise congenital absence of 
the larger portion of the pectoralis muscle. 

Rudimentary development is more common ; indeed, in many women 
of the present day, unless stimulated by conception, the breasts are 
poorly developed, and even gradually undergo a certain amount of 
atrophy. Usually when the breasts are rudimentary the pelvic sexual 
organs will be found in a similar imperfectly developed condition, the 
ovaries being either infantile or entirely absent. 

Supernumerary mammary glands (polymazia) are by no means so 
very uncommon, the most frequent form being an additional nipple in 
the neighborhood of the normal mamma, either below or close to the 
axilla. The accessory breast is usually much smaller than the normal 
one, but in nursing-women will be found to secrete milk proportionally 

Fig. 341. 




Robert's Case of Supernumerary Nipple on the Thigh. 1 

quite as freely as the former. A number of observers have reported 
meeting with four mammae in one woman (Cooper, Lee. Shannon, 
Champion, and Gardner). Robert reports the case of a woman whose 
mother had a double nipple, and she herself had a supernumerary 
mamma with nipple on the outer surface of the left thigh, from which 
1 Witkoski, Histoiredes Aceouchemmts. ISS-. 



796 DISEASES OF THE FEMALE MAMMARY GLANDS. 

milk was secreted. (See Fig. 341.) It is curious to say that some 
cases are on record in which supernumerary nipples have been observed 
in the male sex. Thus Sanderson saw five nipples in a man, two being 
at the centre of the thorax, two in the axillary spaces, and a median 
one between umbilicus and sternum. 

Obviously, very little can be done for any of the above-mentioned 
congenital conditions. A supernumerary mamma would be removed 
only if it became diseased or gave rise to inconvenience of some kind 
sufficient to warrant operative interference. 

Absence or retraction of the nipple is a very common occurrence, 
and usually attracts attention first when the young expecting mother 
presents herself to a physician to engage his services in her confine- 
ment. The nipple may be found entirely wanting, or it may be so 
small or even retracted that it is absolutely useless for purposes of lac- 
tation. Nothing can be done for these cases when a thorough exam- 
ination has satisfied the physician that it is impossible to develop the 
imperfect nipple by gradual pressure or manipulation. In cases where 
the nipple is capable of erection on manipulation an attempt should be 
made to force it outward by means of properly-fitted and constantly-worn 
nipple-shields. The discussion of this subject belongs to obstetrics. 

Besides the excoriations and fissures produced by lactation, the nip- 
ple and areola are subject to two affections — eczema and a peculiar 
malignant ulcer first described bv Sir James Paget, and called after 
him " Paget's disease." The diagnosis of both conditions is easy, the 
malignant type being recognized by its spreading and resistance to 
treatment and by the pain it causes. Eczema of the nipple should be 
treated like that disease elsewhere ; that is, by zinc, lead, or white 
precipitate ointments, or by scrubbing with green soap and diachylon 
plaster. The malignant disease may possibly be cured by the actual 
cautery or a strong solution of chloride of zinc, but most certainly by 
complete early excision. 

Inflammation of the Breast (Mastitis). 

The consideration of acute inflammation of the breast following con- 
finement really does not belong in the present work. We will briefly 
refer to it merely for completeness' sake, and in order to bring before 
the profession again a method of treating abscesses of the puerperal 
breast which has been so successful in our hands that we cannot refrain 
from once more reporting it. As a rule, inflammation of the puerperal 
breast is a direct consequence either of transmission of inflammation or 
of septic infection from a cracked or abraded nipple. More rarely, the 
pressure of a corset and accidental injury or retention of milk in the 
deeper acini of the gland, acting as an irritant, will cause such inflam- 
mation. The persistence of nursing in cases of injured nipple or of 
so-called "caked," swollen, and tender breast is often to blame for the 
progress of the inflammatory process to such a degree that suppuration 
finally results. An injury, such as a blow or friction of the corset, may 
excite inflammation and suppuration in a non-puerperal breast. We 
(P. F. M.) have a case at present under our care of a young girl of 



INFLAMMATION OF THE BREAST. 797 

seventeen, in whom a bruise received four months ago resulted in an 
abscess of the left breast, which, treatment in other hands having failed, 
we hope to cure by the method here described. .Besides inflammation 
and suppuration of the gland itself, the formation of an abscess under- 
neath the gland — that is, between its fascia and the pectoralis major 
muscle, so-called submammary abscess — is not of very rare occurrence. 

Symptoms and Course. — The first symptom of acute inflammation 
of the gland is usually pain radiating from the nipple in the direction 
of the affected portion, which is felt to be hard, nodular, and tender. 
Occasionally the skin is seen to be reddened over the inflamed part. 
The inflammation may begin with a chill, and usually there is more or 
less rise of temperature. Unless the process is controlled, it, in a large 
proportion of cases, goes on to suppuration. The pus, unless evacuated 
early, burrows its way between the acini and lobes of the gland, and 
honeycombs the latter as it were, breaking down all the interlobular 
areolar tissue. If the abscess is not opened, the pus usually will in 
time find its way toward the surface in one or more places. This pro- 
cess may extend over weeks and even months, one portion after the 
other of the breast breaking down, and its contents being evacuated 
through one or more small openings in the skin. 

Submammary abscesses differ in this respect, since they usually, 
being deep-seated, do not open spontaneously, but the pus continues to 
increase until the intact mamma above the abscess-cavity floats on 
the subjacent fluid. If the latter is now evacuated by a deep lateral 
incision, the mamma will at once return to its normal position on the 
pectoralis major muscle, and all evidences of the presence of an abscess 
will have disappeared. 

The diagnosis of a puerperal mastitis is so easy that scarcely a word 
need be lost on the subject. The presence of pain, fever, swelling, and 
redness, together with the history, ought to make the case clear at 
a glance and distinguish the condition from any chronic enlargement 
or tumor of the organ. 

The prognosis, so far as restoration to health is concerned, is always 
good, since but a very infinitesimal proportion of cases of puerperal 
mastitis terminate fatally ; but so far as the saving of the breast for 
future functional activity or of an arrest of the inflammatory process, 
no such favorable outlook can be promised. A breast that has once 
been thoroughly honeycombed by suppuration, in which indeed more 
or less of the glandular tissue has been destroyed, will probably shrink 
and atrophy after the suppuration has been arrested, and its functional 
activity is most likely gone for ever. Hence it must be our object to 
avoid allowing such extensive destruction of the breast to take place, 
and this is best done by an early evacuation of the pus and closing of 
the abscess-cavity in the manner hereafter to be described. 

Treatment. — Acute Stage. — It must of course be our object to cut 
short an inflammation of the puerperal breast as rapidly as possible, not 
only in order to save the mother pain and suffering, as well as to pre- 
serve for her the usefulness of the organ, but also" for the sake of the 
child. The methods of ostensibly cutting short an acute mastitis are 
very numerous, but unfortunately not as successful as numerous. 



798 DISEASES OF THE FEMALE MAMMARY GLANDS. 

Some authors claim that the application of ice will always check an 
acute mastitis, but not every puerperal woman can bear the long-con- 
tinued application of cold. Others, again, believing that a mastitis 
always extends through septic infection from fissured nipples, claim 
that the spread of the infection and resulting inflammation can be pre- 
vented and cured by the use of antiseptic lotions to the nipple, chiefly 
solutions of bichloride of mercury. It is obvious that the free and 
necessarily somewhat careless use of these poisonous lotions must be 
fraught with danger to the child, which might easily, if allowed to nurse, 
get some of the wash into its mouth ; the nurse, with a carelessness not 
entirely unknown to that very useful and necessary class of persons, hav- 
ing forgotten first to wash and dry the nipple. Finally, the largest propor- 
tion of physicians believe, with the best show of reason, that the only safe 
and sure way of preventing the extension of a puerperal mastitis is to 
immediately withdraw the child from the breast, and exert steady com- 
pression by means of systematically and equably applied compresses 
of cotton and roller bandage to the inflamed organ. Many, indeed, 
claim that it is necessary to stop nursing, even on the as yet healthy 
side, because the irritation of the inflamed breast is thereby increased. 
There can be no question that any case of acute puerperal mastitis can 
be checked in its early stages by the complete cessation of the function 
of lactation and the uniform compression of the affected organ. This 
compression should be continued until all pain and fever has subsided, 
the bandage not being changed for several days, or if removed immedi- 
ately replaced. This treatment, be it understood, should, however, 
never be employed when there is the least sign or suspicion of suppu- 
ration. We do not wish to say that every case of fissured nipples or 
of mild adjacent inflammation must necessarily be treated in this 
manner, and that cessation of nursing is imperative in every instance. 
Undoubtedly, the use of solutions of alum in glycerin, sulphate of 
zinc, tannin, nitrate of lead, compound tincture of benzoin, and of 
numerous other favorite remedies which we cannot mention here, but 
of which Ave should not forget to note nitrate of silver, either in stick 
or 60-grains-to-the-ounce solution, will frequently heal superficial fis- 
sures and erosions of the nipple, and under judicious management of 
the function of lactation the breast will gradually recover its normal 
condition. But we feel perfectly safe in maintaining that any well- 
marked inflammation of one or more of the lobes of the gland will 
scarcely ever yield to any treatment except to that of rest and the 
compression above referred to. 

If, unfortunately, the inflammation has been allowed to go on to 
suppuration, or has persisted in doing so in spite of the usual treatment 
of flaxseed poultices, ointments, gentle expression and rubbing of the 
breast, in addition to suspension by a cloth tied around the neck, then 
it becomes the duty of the surgeon to evacuate the pus as soon as its 
presence and location can be detected. 

The incision should be made as carefully as possible, so as not to 
wound either large blood-vessels or lacteal ducts, and should therefore 
extend in a radiating direction from the nipple to the circumference of 
the breast. The pus having been evacuated, the abscess-cavity should 



INFLAMMATION OF THE BREAST. 799 

be syringed out with a 1 : 10,000 solution of bichloride, and then the 
method employed which we have found invariably successful, and 
which we will now describe : 

A large, coarse bathing sponge has been procured, thoroughlv 
cleansed of sand and impurities, and soaked in boiling water until it 
has become perfectly soft. The sponge should be sufficiently large to 
cover the whole diseased breast, and its centre should be cut out so as 
to make room for the larger portion of the organ. This sponge is now 
soaked in a 2 per cent, carbolic-acid solution, the water being as hot 
as the hands can endure. The sponge is rapidly squeezed, so as to be 
nearly dry, and is then placed over the breast, so as to leave the open- 
ing of the abscess projecting into the centre of the sponge. A piece 
of oiled silk large enough to cover the sponge is then placed over it, 
and the latter gently but firmly pressed to the thorax by means of suc- 
cessive turns of a broad roller bandage or by means of two wide three- 
cornered cloths, one of which passes around the thorax and is tied at 
one side, and the other upward and under one arm and tied behind the 
neck. The latter method is the one which we formerly employed, but 
we think the roller bandage, while a little more troublesome of applica- 
tion, unquestionably more comfortable. The steady compression of 
the breast by the sponge ensures the non-accumulation of pus in the 
abscess-cavity, and a consequent approximation of its walls, which, if 
the sponge is properly applied and the compression of the bandage 
intelligently exerted, must infallibly result in a closure of the abscess 
in the course of from four to six days, according to the duration of the 
abscess and the amount of suppuration. The dressing may have to be 
removed once or even twice daily, the sponge thoroughly cleansed, and 
immediately reapplied in the manner described. We have never found 
it necessary to use more than one bichloride injection into the cavity 
of the abscess. Usually one daily dressing is sufficient. By this treat- 
ment we have cured within one week abscesses which honeycombed the 
breast in every direction, and which on first being opened exuded not 
less than six to ten ounces of pus. We have recently succeeded in 
curing in less than three weeks a case of suppurative puerperal mastitis 
which had been treated for three months by other surgeons with the old 
method of daily irrigation and packing with iodoform gauze [P. F. M.] : 
which latter treatment, although perfectly legitimate in abscesses situated 
in portions of the body where this system of steady compression cannot 
be exerted as it can be over the thorax, certainly is entirely out of 
place and unsuccessful in mammary abscesses. This same species of com- 
pression can, we admit, be applied by means of absorbent-cotton com- 
presses covered with a roller bandage or by strips of adhesive plaster ; 
which latter method has been very highly recommended by many 
eminent authorities, but we claim in favor of the hot wet sponge a com- 
pressive power which none of the other agents possess. At times the 
compressive effect of the sponge must be aided by small wads of 
absorbent cotton or wound roller bandages so distributed around the 
edges of the abscess as to compress those portions which escape the 
action of the sponge. The object is to prevent any accumulation o\' 
pus in the cavity of the abscess, and to keep fts walls so closely and 

51 



800 



DISEASES OF THE FEMALE MAMMARY GLANDS. 



steadily in apposition that they cannot fail to adhere. If this practice 
can be properly carried out, it is merely a question of time, and that 
a short one, for the healing of any abscess. 

Submammary abscesses are even easier to cure by this method than 
those of the gland itself. 



Tumors of the Breast. 

Benign. — Diffuse Hypertrophy. — This is a very rare affection, but 
few cases have been seen by even the most experienced observers. 
Billroth reports two, Winckel one, Cooper, Gross, Erichsen, and some 
half a dozen others, one case each. Curiously, a number of these 
cases have been observed in young girls between fourteen and sixteen 
years of age, in whom the enlargement of the breasts made its appear- 

Fig. 342. 




Crofford's Case of Diffuse Hypertrophy of the Breasts. 

ance soon after the inception of puberty. One of the most remarkable 
cases as regards size is mentioned in the June (1891) number of the 
American Journal of Obstetrics, the case being reported by Dr. T. G. 
Croiford of Memphis, Tenn. The girl was fifteen years of age, and 
the enlargement of the breasts began soon after the first menstruation, 
early in her fifteenth year. The largest circumference of the breasts 



TUMORS OF THE BREAST. 801 

from the front base over the nipple and back to the starting-point was 
82 J inches on the right and 35 \ on the left side. (See Fig. 342.) 
The cause of this enormous, mostly very rapid, enlargement of the 
breasts at this time of life is not known, except that we may infer that 
the beginning of the sexual period, which usually ushers in a physi- 
ological enlargement of the mammary gland, in some cases excites an 
excessive development. There is only one treatment, and that is 
removal of the organ. Compression has been tried in vain. 

Fibroma of the female breast is not very uncommon. One or more 
such tumors may be found in the gland at the same time. Their 
growth is very slow, sometimes extending over a period of years. 
Billroth mentions one which he had under observation for ten years, 
without any material change during that time. Usually they are small 
in size, seldom reaching that of a hen's egg. According to Velpeau, 
they are found most frequently in unmarried or sterile women. 

These true fibroids must not be confounded with nodular enlargements 
of the breast, which occur very frequently, apparently as the result of 
reflex engorgement preceding menstruation. We have seen many cases 
in which immediately preceding the menstrual period one or more such 
hard, sensitive nodules appeared in one or both breasts. They were 
undoubtedly merely produced by localized hyperemia of certain lobules 
of the breast incident to the approach of the menstrual period, and dis- 
appeared after the flow had been properly established. As a rule, such 
women were sterile and the menstrual Aoav was scanty in amount. We 
are inclined to think, however, that true fibroma of the breast may take 
its inception from a frequent recurrence of such premenstrual congestion. 

Fibroma of the breast is not in itself a disease of any special dan- 
ger or importance, but the rule applies to this form of mammary tumors 
as well as to all others which are not as yet malignant — namely, that 
any tumor of the female breast is liable to malignant degeneration at 
some period of its existence, which period can never be foreseen or 
prevented. Hence it is wise to treat all such tumors on the general 
principle to remove them by the knife as soon as their existence is 
recognized. It is true, unnecessary operations may thus be at times 
performed, but it is better to perform a dozen unnecessary operations 
than to postpone a single necessary one until it is too late to effect a 
permanent cure. These tumors are usually not attended by very much 
pain, the occurrence of which would generally lead to a suspicion of a 
change of type of the tumor from a benign to a malignant character. 

Lipoma of the female breast is by no means as common as fibroma : 
indeed, Billroth doubts whether a true fatty degeneration of the tissue 
of the breast itself occurs, since in the only case which he has witnessed 
the tumor developed behind the gland, where it grow to an enormous 
size, pushing the gland before it and causing atrophy of the latter. Sir 
Astlcy Cooper and Velpeau each mention a case. 

The progress of the disease is slow, and in no way differs from that 
of lipoma in other portions of the body. It produces discomfort only 
by its size, and the only treatment is removal. 

Adenoma is likewise a rare affection in the female breast. It niav 
oocurin two varieties, the solid and the cystic. According to Billroth, 



802 DISEASES OF THE FEMALE MAMMARY GLANDS. 

the nature of the growth is very similar to that of sarcoma and cysto- 
sarcoma, into which it may eventually merge. The cases are so rare 
that no distinct clinical picture can be given of the progress and appear- 
ance of the disease. We must refer the reader to Billroth's excellent 
treatise on " Diseases of the Female Mammary Gland," found in the 
Cyclopaedia of Obstetrics and Gynecology, a translation of which was 
published by William Wood & Co. in 1887, for a more detailed descrip- 
tion of this disease. 

Cysts containing serum, milk, and a butter- or mortar-like substance 
are occasionally met with in the female mamma. A few instances of 
development of the parasite known as the echinococcus or Cysticercus 
celluloses in the female breast are on record. The nature of this cyst 
can be ascertained only by examining the removed fluid under the 
microscope. Those containing milk result from the dilatation of a 
milk-duct, the efferent extremity of the duct being occluded in conse- 
quence of inflammatory adhesion. This condition is called galactocele. 
Cysts with the other contents mentioned usually result from a puerperal 
mastitis. 

The diagnosis of these cysts is not difficult, but the nature of their 
contents can be ascertained only by aspiration or exploratory incision. 
The progress is slow ; indeed, they are very apt to remain stationary 
for a long time, excepting those containing milk, which, if the patient 
should nurse at the same time, would probably increase in size in con- 
sequence of the maintenance of the functional activity of the organ. 

The prognosis of these • cysts is always good, since they show no 
tendency to malignant degeneration. On the principle, however, 
already enunciated, that all tumors of the female breast should be 
removed for fear of their eventually becoming malignant, we would 
advise the same course in relation to cysts. An exception to this rule 
should be made in favor of galactocele, the incision and drainage of 
which would probably result in a cure. 

Enchondroma or a cartilaginous degeneration of the mammary tissue 
is so rare that its occurrence need hardly be mentioned. 

Malignant Tumors. 

Sarcoma. — Three kinds of solid sarcoma of the breast are usually 
described — the medullary, the alveolar melano-sarcoma, and the alveolar 
giant-celled sarcoma. This affection is by no means as common in the 
breast as the true variety of malignant disease — namely, carcinoma. 

The histological peculiarities of these different forms of sarcoma are 
expressed in a general manner by the names given to the varieties. 
The soft or medullary sarcoma resembles macroscopically the tissue of 
the brain; under the microscope many small round cells, some fat 
tissue, and striated muscular fibres (Billroth) may be recognized. The 
alveolar melano-sarcoma shows numerous small cells arranged in nests, 
with brownish-black pigment scattered throughout the growth, and in 
the alveolar giant-celled variety the cells are large, caudate, and arranged 
in bundles and nests. 

Cysto-sarcoma of the breast is more common than the solid form, 



MALIGNANT TUMORS. 



8(KJ 



Billroth reporting as many as nineteen cases seen by himself. The 
tumors sometimes attain very great size, one reported by Velpeau weigh- 
ing forty-four pounds. On account of the tendency of these growths to 
increase rapidly by a formation of new cysts and the growth of poly- 
poid excrescences in these cysts, the name of "proliferating cysto-sar- 
coma" is usually given to this disease. These tumors are found most 
frequently between the twentieth and fortieth years, and are more com- 
mon in the married and in women who have borne children than in the 
unmarried. They are always encapsulated and movable in the gland, 
and vary considerably in the rapidity of their growth. They are 
usually not painful to light touch. Although not so rapidly fatal as 
true carcinoma, cysto-sarcoma still eventually causes death by ulceration 
and breaking down of the tumor and consequent marasmus. Rapid 
recurrence after removal is reported to be the rule. 

Carcinoma. — There is still considerable confusion in the designation 
of the different varieties of cancer of the female breast, the authorities 
of different countries calling one and the same form by different names. 
In order not to confuse the reader, we will quote from Billroth the 
designations of each variety employed by the German, English, and 
American schools of medicine : 

1. Acinous carcinoma, with partly softer, partly harder nodules 
(German, Billroth) ; medullary carcinoma, tuberous form of cancer 
(English, Birkett) ; encephaloid, tuberous form of cancer (American, 
Gross). 

2. Carcinomatous infiltration, histologically tubular carcinoma, 
carcinoma simplex (German, Billroth) ; intraglandular carcinoma, 

Fig. 343. 




Large Isolated, Soft Carcinoma Nodule (fungus medullaris) on an atrophied mamma, ■with 
small involution-cysts; very complete substitution of the mammary bv fatty tissue. One- 
third natural size. 

infiltrated form of cancer (English, Birkett) ; infiltrated form o\' can- 
cer (American, Gross). 

3. Atrophying contracting cancer, scirrhus (German, Billroth); 
atrophic scirrhus (American, Gross). 

4. Colloid cancer, gelatiniform cancer (Gross). 

It is not our purpose to enter into the details of the histological 



804 



DISEASES OF THE FEMALE MAMMARY GLANDS. 



characteristics of these different varieties of cancer of the breast ; suf- 
fice it to say that, according to the greater or lesser predominance of 
cellular elements or of fibrous tissue the tumor belongs to the soft varie- 



Fio. 344. 





W/im PHI 

ISM 







Cicatrizing Mammary Carcinoma, with marked retraction of the nipple ; considerable develop- 
ment of fat in place of the mamma. Almost natural size. 

ties described under Figs. 339 and 340, or to the hard variety described 
under Fig. 347. The cancer-cells are scattered without any special 
regularity throughout the tumor, being separated into greater or lesser 

Fig. 345. 




Typical Picture of a Mammary Carcinoma (Hartnack, Syst. 5). 

nests and columns by bundles of connective tissue. The form desig- 
nated by Billroth as tubular carcinoma is characterized by the out- 
growths of the epithelial mass in the form of elongated ramifying 



MALIGNANT TUMORS. 



805 



Fig. 346. 




From the 



Limiting Layer of an Acinous Carcinoma of the Mamma (Hartnack, Syst. 2). 



cylinders or filled tubes. (Figs. 343, 344, 345, 346, and 347, taken 
from Billroth, give an idea of the macroscopical and histological appear- 
ances of the different varieties of cancer of the breast.) 



Fig. 347. 




From the Boundary Layer of a Tubular Infiltrated Carcinoma, pushing forward into the sur- 
rounding fatty tissue (upward) (Hartnack, Syst. 5;. 



Frequency and Course of Cancer of the Female Breast. — Unfor- 
tunately, this disease is exceedingly common, being. Ave believe, even 
more common in the female sex than cancer in that other favorite local- 



806 DISEASES OF THE FEMALE MAMMARY GLANDS. 

ity, the cervix uteri. Either breast may be affected, but it is unusual 
to find carcinoma of both breasts at the same time. The outer side of 
the breast is most usually the part affected, the infection spreading with 
more or less rapidity to the axillary and infraclavicular glands. This 
infection is most likely to take place within from twelve to fifteen 
months after the beginning of the disease, very often indeed very much 
earlier. The softer the variety of the cancer, the more rapid and exten- 
sive is the infection of the axillary glands. Usually, when these glands 
have become involved, the pressure upon the axillary nerves causes 
so much pain that the health of the patient begins to deteriorate, if 
indeed it has not done so before, in consequence of the softening and 
breaking down of the tumor, with profuse offensive ichorous discharge. 
Extension of the cancerous infiltration to the pleura and metastases in 
the lungs, liver, and other distant organs are liable to occur in the later 
stages and to hasten the fatal issue. Metastasis even to the bones and 
brain is reported by Billroth and Von Winiwarter. 

The termination of cancer of the breast is invariably fatal. We are 
not aware that there are any cases on record in which spontaneous cure 
has occurred, either in consequence of sloughing and cicatrization of 
the breast or spontaneous absorption of the tumor. 

Duration of the Disease. — The average duration of life in a woman 
with carcinoma, dating from the time when the disease was first noticed, 
is, according to Paget, Sibley, and Winiwarter, between thirty-two and 
thirty-six months. The same authors give the average duration of life 
in operated cases as about fifty months — a comparatively slight gain 
which would scarcely seem to repay the patient for the risk incurred 
in the operation. 

Causes. — These are practically unknown, since in the majority of 
cases no distinct factor can be discovered upon which the blame for 
the production of the disease can be positively laid. Heredity does 
not seem to play a greater role in the tendency to cancer of the 
breast than it can be proved to play in the same disease in any other 
organ. The fact that cancer of the breast occurs most frequently in 
married women, especially those who have borne children, would seem 
to indicate that the irritation produced by lactation has a predisposing 
influence. Possibly puerperal inflammation of the gland and injuries 
to the nipple may exert such an influence. Accidental injuries, such 
as blows, and possibly the steady pressure and friction of the corset, 
may also be looked upon as instrumental ; but usually no positive 
cause can be ascertained. 

Symptoms. — The first symptom which a woman usually notices is 
the accidental discovery of a small lump in her breast, situated near, 
generally on the outer side of, the nipple. Occasionally her attention 
may have been first called to the organ by sharp darting pains through 
it, when the hard nodule is discovered. In one case which we operated 
upon (P. F. M.) the first symptom noticed by the patient was the 
retraction of the nipple, which led her to feel of her breast, when she 
discovered a hard mass occupying the centre of the gland. Operation 
proved this to be a well-marked contracting scirrhus. Unfortunately, 
very often the attention of the patient is not called to the presence of 



MALIGNANT TV MORS. 807 

a growth in her breast until the axillary glands have already become 
involved; which fact accounts for the relatively poor results of extir- 
pation of the diseased tissues, since it is usually impossible to com- 
pletely remove the carcinomatous axillary glands. The pain in the 
earlier stages is usually confined to the breast itself, but when the 
axillary glands once become involved the most severe pain is felt on 
the inner side of the arm on the affected side, owing to the pressure 
on the brachial plexus of nerves. 

Treatment. — There is probably no one form of disease the cure of 
which has become so much the province of the charlatan as cancer of the 
female breast. Innumerable nostrums have been and are still being 
advertised for this fearful disease, and thousands of women have been 
tortured by means of caustics and various local applications intended to 
produce sloughing of the diseased tissues and cicatrization of the wound. 
It is needless to say that almost without exception all such remedies 
are useless. Occasionally, after intense suffering, by a mere lucky 
chance, all the diseased tissue may be destroyed by sloughing and sup- 
puration, and a cure result, but it is, in truth, dearly bought. The only 
proper treatment and the only means of effecting a sure cure, provided 
the case comes under observation early enough, before the axillary 
glands are involved or the disease has spread to the pleura and ribs, is 
to remove the whole breast — and nothing less than the whole breast will 
answer — by the knife. The old method of endeavoring to save a por- 
tion of the breast, and to remove only that part which appears hard or 
affected by cancerous infiltration, has been abandoned by the majority 
of surgeons, and at present the object of the operator is to excise 
every particle of the mammary gland, whether it appears diseased or 
not, and to complete the operation by a careful survey of the wound 
and the removal of every, no matter how minute, particle which appears 
in the least degree suspicious. The details of the operation need not 
be described, except to mention that it is of course performed under 
antiseptic precautions, that the wound is closed by catgut sutures 
throughout, the drainage-tube being carried from the most dependent 
portion of the wound out through a slit made in the skin, usually on 
the side of the thorax. The dressings are of the usual protective and 
aseptic variety, and are not changed for perhaps a week, unless a rise 
of temperature should call for an inspection of the wound. Usually, 
if everything goes well, at the expiration of a week, when the dress- 
ings are removed, the wound will be found completely closed, the dis- 
charge from the drainage-tube practically absent, and the latter can be 
removed. The dressing is then reapplied, and when again removed, at 
the expiration of the second week, the drainage puncture is closed and 
the patient can be discharged. 

Danger of the Operation. — The danger of the operation in itself 
is comparatively trifling, the removal of the breast alone scarcely 
ever resulting fatally, while when the axillary glands were involved. 
according to Billroth, 10.5 per cent, resulted" fatally in his prac- 
tice. 

The prospects of permanent cure by the operation depend entirely 
upon the possibility of removing the whole diseased tissue — therefore 



808 DISEASES OF THE FEMALE MAMMARY GLANDS. 

upon the earliest possible performance of the operation before the 
implication of .the axillary glands. 

Billroth quotes Weeden Cook as having collected 413 operated 
cases of carcinoma of the breast, 409 of which remained free from 
recurrence for six and a half months, and a later recurrence took place 
in 4 other cases. Winiwarter gives 91 cases, with recurrence in 27.4 
per cent, before closure of the wound, in 38.4 per cent, within the first 
month, and in 34.1 per cent, later than the fourth month. Among the 
last series the recurrences were so frequent that their total within the 
first quarter of the year after operation amounted to 82.4 per cent, of 
all cases. Manifestly, the operation was of very little use or benefit in 
cases so far advanced as these must have been ; and it is questionable 
to us whether it is worth while to subject a woman with cancer of the 
breast so far progressed that a recurrence is inevitable within a few 
months, to the risks and inconveniences of a partial extirpation. Bill- 
roth has seen 15 authenticated cases of mammary carcinoma in which 
there was an absence of recurrence for a period ranging from twelve 
years, the longest, down to thirteen months, the shortest time after the 
operation. Several cases are reported by Billroth and other surgeons 
in which a permanent cure — that is, so long as the patient kept under 
observation — was not achieved until after a second and even a third 
operation. Unquestionably, when the cancer is limited to the mammary 
gland a complete and permanent cure can be achieved, and indeed should 
be expected, if the surgeon is careful to remove the entire gland. 

In order to avoid the mutilation necessarily accompanying a large 
cutaneous incision. Thomas has suggested opening the skin in a line 
parallel with the sulcus between the lower margin of the breast and the 
thoracic skin, and dissecting out the breast from that direction. We 
believe, however, that this method was intended only for non-malignant 
tumors, since a mere question of aesthetics would scarcely warrant the 
possibility of an incomplete extirpation. 



INDEX 



A. 

Abdomen, regions of the, 362 
Abdominal bandage for support of pelvic 
viscera, 177 

hysterectomy for fibroids, 532 

incision for replacement of inverted ute- 
rus, 457 

palpation in diagnosis, 81 

pregnancy, 769 

supporter, 411 
Abortion, criminal, as a cause of disease, 

43 
Abscess as a cause of fistula?, 248 

mammary and submammary, 797 

of the ovary, 658 

of the vulvo- vaginal glands, 155 

pelvic, 464, 493 

causes, 493 

course, duration, and termination, 494 

differentiation, 494 

pathology, 493 

physical signs, 494 

prognosis, 495 

symptoms, 493 

treatment, 495 

by evacuation, 496 
best point for, 497 
means for causing closure of sac, 499 
methods of operating, 498 
Acid, carbolic, as an antiseptic, 61 
Acne of the vulva, 135 
Adenoma, multiple, 339 

of the breast, 801 

of the cervix, 556 

of the uterus, 556 

causes, 557 

differential diagnosis, 557 

pathology, 556 

prognosis, 557 

symptoms, 557 

treatment, 558 

varieties, 556 
Adeno-myxo-sareoma of cervix, 547 
Air, entrance into vagina from lacerated 

perineum, 168 
Alexander's operation for prolapsus, 399 

for retro-displacements, 440 
Ama/.ia, 79-1 
Amenorrhea, 600 

causes, 603 

definition, 600 

significance of, 605 

treatment, 606 



Amputation of cancerous cervix by gal- 
vano-cautery, 581 
of uterus for inversion, 459 
methods of operating, 461 
results, 461 
Anaesthesia in diagnosis, 77 
Androgyne, 121 
Angioma, urethral venous, 154 
Anteflexion, cervical, from constipation, 45 
from shortening of sacro-uterine liga- 
ments, 369 
of cervix, diagram of, 788 
of the uterus, 404 

more frequent than retroflexion, 365 
pessaries for, 412 
physical signs, 406 
prognosis, 407 

showing iSims's posterior discission, 792 
symptoms, 405 
treatment, 407 
treatment by operation, 418 
means for reduction, 407 
means of retention, 409 
varieties, 404, 406 
with retroposition, 406 
Anteflexion, slight, of the normal uterus, 

366 
Anteversion of the uterus, 400 

course, duration, and termination, 403 
definition and frequency, 400 
degrees of, 403 
diagnosis. 403 
differentiation, 404 
exciting causes, 401 
extreme, diagram of, 401, 788 
pessaries for, 412 
predisposing causes, 401 
prognosis, 404 
symptoms, 402 
treatment, 407 
varieties, 403 
Antifebrin as an antipyretic, 70 
Antipyretics, use of, 70 
Antipyrine as an antipyretic, 70 
Antisepsis in examinations, 03 
Apoplexy of the ovary, 64S 
Applicator, hard-rubber, 292 
Areolar hyperplasia in uterine pathology, 
51 
of the uterus, 306 
Ascent of the uterus, 377 
Aspirator in diagnosis. 99 

Potain's, 99 
Astringents and tonics in prolapsus. 393 

S09 



810 



INDEX. 



Atresia of the cervix uteri, 233 
of the genital tract, 225 
of the uterus, 229 
of the vagina, 226 

stricture, and stenosis, differentiation, 
225 
Atrophy of labia, nymphse, and clitoris, 

127 
Auscultation in diagnosis, 101 



B. 

Bandage, abdominal, for support of pelvic 

viscera, 177 
Bandaging, tight, after parturition, as a 

cause of disease, 41 
Barrenness, 786 
Barrier's method of replacing inverted 

uterus, 456 
Battey's operation, 747 
Bichloride of mercury as a germicide, 61 
Bimanual palpation in diagnosis, 79 
Bladder, cancer of, 243 

catarrh of, 239 

contraction of, 241 

diseases of, 239 

examination of the interior of, 235 

exstrophy of, 244 

incrustation of, 242 

neoplasms of, 243 

polypi of, 243 

prolapse of, 173 

sloughing from retroflexion, 243 

stone in, 242 
Blennorrhagia, 216 
Blennorrhea, 216 
Bloody tumor of the pelvis, 500 
Brain, overwork of, as a cause of disease, 

37 
Breast, absence of, 794 

adenoma of, 801 

cancer of, 803 

cysto-sarcoma of, 802 

cysts of the, 802 

diffuse hypertrophy of, 800 

diseases of, 794 

fibroma of, 801 

inflammation of, 796 

lipoma of, 801 

rudimentary, 795 

sarcoma of, 802 

supernumerary, 795 

tumors of, 800 
Brewer's trivalve speculum, 84 
Broad ligaments, diseases of, 782 

inflammation of, 463 
Bulbs of the vestibule, rupure of, 136 
Calculus, vesical, 242 
Cancer, epithelial, of the cervix, 564 

of the bladder, 243 

of the breast, 803 
causes, 806 
duration, 806 
frequency and course, 805 
symptoms, 806 
termination, 806 



Cancer of the breast, treatment, 807 
operation, dangers of, 807 
results of, 808 
varieties, 803 
of the uterus, 562 

age, favoring, 569 
causes, 566 
complications, 576 
course and duration, 574 
diagnosis and differentiation, 573, 

577 
frequency, 566 
of the body, 577 
part of uterus affected, 577 
pathology, 563 
physical signs, 571 
prognosis, 574 
symptoms, 571 
treatment, 578 

hysterectomy, 582 
methods, 583 
operation, 584 
results, 587 
indications, 578 
palliative, 589 
radical, 578 

removal of the cervix, 579 
indications, 579 
methods, 580 
varieties, 564 
of the vulva, 128 
superficial, of the cervix, 564 
Capillary sinuses after fistula operations, 

treatment of, 274 
Carbolic acid as an antiseptic, 61 
Carcinoma of the ovary, 662 
Caruncle, irritable urethral, 151 
causes, 151 

course and duration, 152 
pathology, 151 
physical signs, 152 
prognosis, 152 
symptoms, 152 
treatment, 153 
Carunculse myrtiformes, 125 
Catarrh, cervical, 284 
of the bladder, 239 
uterine, acute, 278 
chronic, 292 
Catarrhal endometritis in uterine path- 
ology, 49 
salpingitis, 753 
Catgut, preparation of, 62 
Catheter, Sims's new style, 261 
Sims's sigmoid, 261 
Skene's self-retaining, 262 
soft-rubber, 261 
Catheterization, precautions to be observed 

in, 64 
Causes, exciting, of disease in the female, 
46 
of disease in the female, 34 
predisposing, of disease in the female, 35 
Cellular tissue, pelvic, sarcoma of, 561 
Cellulitis, para-uterine, 463 
causes, 470 



INDEX. 



811 



Cellulitis, para-uterine, complications, 468 

consequences, 473 

course, duration, and termination, 
469 

frequency, 464 

galvanism in, 106 

pathology, 465 

physical signs, 472 

prognosis, 470 

symptoms, 471 

topography, 474 

treatment, 474 
pelvic, 463 
Cervical anteflexion from constipation, 45 
catarrh, 284 

cavity, dilated, diagram of, 288 
constriction, treatment of, 623 
endometritis, chronic, 284 
leucorrhcea, 284 

mucous membrane, anatomy of, 284 
Cervix, adenoma of the, 556 
adeno-myxo-sarcoma of, 547 
amputation for cancer, 581 
anteflexion of, diagram of, 788 
atresia of the, 233 
catarrhal erosion of, 334 
chancre of the, 336 
cystic erosion of, 335 
cystic hyperplasia of, 335 
Cervix, cystic or follicular degeneration 
of, 334 
causes, 335 
pathology, 335 
prognosis, 335 
treatment of, 335 
destruction of, for cancer, 582 
dilatation by dilators, 624 

by incision, 625 
operation, 626 

by sounds, 623 

by tents, 625 
encephaloid of, 565 
epithelial cancer of, 564 
epithelioma of, 564 
epithelioma of, with laceration, 347 
excision for cancer, 580 
excision of projecting lip of, 792 
flexion of the, etiology, 376 
granular degeneration of the, 330, 350 

causes, 330 

course and duration, 332 

frequency, 330 

pathology, 332 

physical signs, 331 

prognosis, 332 

symptoms, 331 

treatment, 332 
lacerated, pathological changes in, 349 
laceration of t he, 345 

in uterine pathology, 49 
mucous patch of the, 336 
papillary erosion of, 334 
scirrhus of, 565 
superficial cancer of, 564 
syphilitic ulcer of (he, 336 
ulceration of the, 329, 350 



| Chancre of the cervix, 336 
Change of life, 599 
Clamp, Munde's ovariotomy, for searing 

the pedicle, 731 
Cleanliness in surgery, 62 
Cleveland's self-retaining Sims speculum, 
87 

suture for lacerated perineum, 208 
Climacteric, 599 
Clitoris, anatomy of, 124 

atrophy of, 127 

hypertrophy of, 126 
Closure of external os to sustain partly re- 
placed inverted uterus, 460 

of the canal in uterine pathology, 50 

of the vagina, 268 
Clothing, tight, as a cause of disease, 38 
Clover's ether-inhaler, 719 
Coccygodynia, 157 

causes, 158 

pathology, 157 

prognosis, 158 

symptoms, 158 

treatment, 159 
Cold wet sheet as an antipyretic, 70 
Colpocystotomy, 241 
Colporrhaphy, 178 

Emmet's operation, 180 

for prolapsus, 398 

Hegar's operation, 184 

Lefort's operation, 184 

Sims' s operation, 179 

Stoltz's operation, 182 
Columns of the vagina, 217 
Conception, prevention of, as a cause of 

disease, 42 
Condylomata of the vulva, 127 
Congestion, prolonged, in uterine path- 
ology, 49 
Congestive dysmenorrhcea, 619 
Conjoined manipulation in diagnosis, 79 

practice of, 80 
Connective or muscular tissues, excessive 
growth in uterine pathology, 49 
Constant current, use of, 104 
Constipation, habitual, as a cause of dis- 
ease, 44 
Contraction of the bladder, 241 
Corporeal endometritis, chronic, 292 
Corpus luteum of menstruation, 639 

of pregnancy, 640 
Corrosive sublimate as a germicide, 61 
Corsets, deleterious effects of, 39 
Counter-pressure hook, Munde's, 259 
Courty's method of replacing inverted 

uterus, 456 
Crucial incision of external os. 291 

for dysmenorrhcea or sterility. 627 
Cup and stem for replacing inverted uterus. 

453 
Curette, dangers of the, 344 

dull, in diagnosis. 98 

Munde's Hat sharp, 343 

Kecamier's. 343 

sharp, 291 

Situs's steel. 343 



812 



INDEX. 



Curette, Thomas's dull wire, 343 
Current, constant, use of, 104 

faradic, diseases in which it is useful, 
103 
use of, 103 
Cutter's pessary, 437 

prolapsus pessary, 396, 397 
Cyst and abscess of the vulvo-vaginal 

glands, 155 
Cystic degeneration of the cervix, 334 
erosion of the cervix, 335 
hyperplasia of the cervix, 335 
Cystitis, 239 
causes, 239 
prognosis, 240 
symptoms, 239 
treatment, 240 
Cysto-carcinoma of the ovary, 666 
Cystocele, 173 

Gehrung's pessary for, 177 
Stoltz's operation for, 182 
the cause or result of vaginal prolapse, 
174 
Cysto-fibroma of the ovary, 667 
Cystomata, ovarian, 672 
Cysto-papilloma of the ovary, 667 
Cysto-sarcoma of the breast, 802 

of the ovary, 667 
Cvsts, dermoid, of the ovary, 667 
'of the breast, 802 
ovarian, 672 

intraligamentous, 745 
irremovable, 744 
vaginal, 235 



I>. 



Davidson's syringe, 66 
Deformities of vulva, 126 
Degeneration, cystic or follicular, of the 
cervix, 334 
fungoid, of the endometrium, 338 
fungous, of the uterine mucous mem- 
brane, treatment, 614 
granular, of the cervix, 330 
Depressor, Sims's, 85 
Dermoid cysts of the ovary, 667 
Descent of rectal and vesical walls from 
lacerated perineum, 165, 166 
of the uterus, 378 
Development, excessive, of the nervous 
system as a cause of disease, 37 
of generative organs, 110 
physical, neglect of, as a cause of dis- 
ease, 36 
Diagnosis, abdominal palpation in, 81 
abdominal palpation conjoined with the 

use of the sound in, 81 
anaesthesia in, 77 
aspirator in, 99 
auscultation in, 101 
bimanual palpation in, 79 
conjoined manipulation in, 79 
digital eversion of the rectum in, 82 
dull curette in, 98 
exploring needle in, 39 



I Diagnosis, imperfect, a cause of failure in 
treatment, 53 
inspection in, 78 
manikin figure for teaching, 102 
physical, 77 
microscope in, 100 
of the diseases of the female genital 

organs, 71 
percussion in, 101 
speculum in, 83 
tents in, 93 
uterine sound in, 90 
vaginal touch in, 78 
Diet, general system of, in pelvic diseases, 

57 
Digital eversion of the rectum in dia- 
gnosis, 82 
Dilator, Goodell's, 624 

Palmer's, 624 
Dilators, Molesworth's cervical, 528 
Displacement in uterine pathology, 49 
of the ovaries, 650 

uterine, a common cause of subinvolu- 
tion, 41 
Displacements of the Fallopian tubes, 766 
of the uterus, 358 
causes, 373 

general considerations on, 358 
varieties, 364 
Distortion and stricture of the Fallopian 

tubes, 758 
Double touch, 82 
Douche-pan, 66 
Drainage-tubes, 738 

Dress, improprieties of, as a cause of dis- 
ease, 38 
Dressing- forceps, Munde's uterine, 64 

Thomas's, 64 
Drysdale's cell, 679 
Dysmenorrhoea, 615 

congestive or inflammatory, 619 
definition, 615 

due to aggravated flexion of the uterus,. 
373 
membranous, 628 

differentiation, 630 
etiology, 628 
pathology, 628 
prognosis, 631 
symptoms, 630 
treatment, 631 
neuralgic, 50, 616 
causes, 616 
differentiation, 617 
galvanism in, 107 
prognosis, 617 
symptoms, 617 
treatment, 617 
obstructive, 620 
causes, 621 
differentiation, 622 
galvanism in, 107 
pathology, 620 
prognosis, 623 
relation to flexion, 372 
symptoms, 622 



INDEX. 



813 



Dysmenorrhea, obstructive, treatment of 
cervical constriction, 623 
by operation, 626 
treatment of cases due to fibroids, 627 
due to flexion or version, 627 
due to obturator hymen, 627 
due to polypus, 627 
due to vaginal stricture, 627 
ovarian, 632 

pathology, 633 
prognosis, 534 
symptoms, 633 
treatment, 634 
pathology, 615 
seat of pain in, 616 
varieties, 616 
causes, 619 
differentiation, 619 
prognosis, 620 
symptoms, 620 
treatment, 620 
Dysmenorrhoeal membrane, 631 



E. 



Ectopic gestation, 768 
Eczema of the nipple, 796 

of the vulva, 134 
Electricity as a therapeutical agent, 102 
Electrodes, Monde's vaginal and cervical, 

104 
Electrolysis in uterine fibroids, 105 
Elephantiasis of the vulva, 128, 135 
Ellerslie Wallace's spring tent, 409 
Elytroplasty, 268 
Elytrorrhaphy, 178 
Emmet's curette forceps, 344 

method of replacing inverted uterus, 

456 
mode of administering vaginal injec- 
tions, 65 
new operation for lacerated perineum, 

204 
operation of colporrhaphy, 180 
scissors, 195 
trocar and canula. 728 
twisting-tongs, 261 
Encephaloid carcinoma, microscopical ap- 
pearance, 569 
of the cervix, 565 
Endocervicitis, 284 
Endometritis, 292 
acute, 277 

causes, 279 

complications, 281 

course, duration, and termination, 

282 
differentiation, 280 
pathology, 281 
physical signs, 280 
prognosis, 2S3 
symptoms, 280 
treatment, 283 
varieties, 278 
catarrhal, in uterine pathology, 49 
chronic cervical, 284 



Endometritis, chronic cervical, causes, 285, 
286 
complications, 287 
course, duration, and termination, 

288 
pathology, 285 
physical signs, 287 
prognosis, 288 
symptoms, 286 
treatment, 289 
chronic corporeal, 292 
causes, 295 
complications, 299 
course, duration, and termination, 

299 
diagnosis, 299 
pathology, 294 
physical signs, 298 
prognosis, 295 
symptoms, 297 
treatment, 299-303 
granular, 339 
hemorrhagic, 339 
hyperplastic, 339 
of subinvolution, 278 
polypoid, 339 
senile, 298 
varieties, 278 
villous, 557 
Endometrium, fungoid degeneration of 
the, 338 
hyperplasia of the, 338 
Enterocele, 175 
Entero-vaginal fistulse, 276 

hernia, 175 
Episiorrhaphy, 269 
Epithelial cancer of the cervix, 564 
Epithelioma, microscopical appearance, 
568 t 
of the cervix, 564 

of the cervix, associated with laceration, 
347 
Erosion, cystic, of the cervix, 335 
Eruptive diseases of the vulva, 134 
Erysipelas of the vulva, 135 
Erythema of the vulva, 135 
Etiology of diseases of women, 34 
Eversion, digital, of the rectum in diagno- 
sis, 82 
Examination of a patient, mode of, 73 
physical, management of patient during, 

75 
tables for, 76 
Examinations, antisepsis in, 63 
Excision of the cervix for cancer, 580 

of projecting lip of cervix, 792 
Exciting causes of disease in the female. 46 
Exercise and physical development, neglect 
of. as a cause of disease, 36 
general system of, in pelvic diseases. 57 
Exploration by whole hand in rectum, 81 
vesicorectal, in diagnosis, 82 
Noeggerath's method, 82 
Exploring needle in diagnosis. 99 
Exposure during menstruation as a cause 
of disease, 40 



814 



INDEX. 



Exstrophy of the bladder, 244 
External os, crucial incision of, 291 

for dysmenorrhea or sterility, 627 
Extra-peritoneal treatment of pedicle, 536 
Extra-uterine pregnancy, 768 

cause of death, 772 

differentiation, 773 

etiology, 768 

pathology, 770 

physical signs, 773 

prognosis, 775 

recognition of varieties, 775 

symptoms, 772 

of approaching rupture, 774 

treatment, 776 

varieties, 769 
Exudations in uterine pathology, 50 

F. 

Failure, reasons for, in the treatment of 

uterine diseases, 53 
Fallopian tubes, anatomy, 751 
diseased and adherent, 763 
laparotomy for, 763 
indications, 765 
results, 765 
palliative treatment, 766 
diseases of, 751 
displacements of, 766 
distortion and stricture, 758 
inflammation, 753 
diagnosis, 757 
results, 758 
symptoms, 757 
treatment, 758 
malformations, 753 
papilloma of, 768 
sounding of, 756 
tuberculosis of, 767 
unusual length of, 754 
Faradic current, diseases in which it is use- 
ful, 103 
use of, 103 
Fascia and ligaments, pelvic, general pathol- 
ogy of, 52 
Fat, balls of, from dermoid cyst, 669 
Fecal fistulse, 274 
Fergusson's speculum, 83 
Fibro-cyst of the ovary, 665 
Fibro-cystic tumors of the uterus, 543 
differential diagnosis, 544 
symptoms, 544 
treatment, 545 
Fibroid tumors of the uterus, 512 
, causes, 519 

complications, 519 

course, duration, and termination, 

522 
differentiation, 521 
electrolysis in, 105 
galvanism in, 107 
interstitial, 516 
pathology, 512 
physical signs, 520 
prognosis, 522 



Fibroid tumors of the uterus, submucous, 
516 
subserous, 516 
symptoms, 520 
synopsis of operative treatment of 

different varieties, 545 
treatment, Atlee's, 527 

by abdominal hysterectomy, 532 
by avulsion, 529 
by electro-puncture, 525 
by enucleation, 530 
by ergot subcutaneolisly, 525 
by excision, 529 
by galvanism, 526 
by laparotomy, 522 
dangers of, 539 
extra-peritoneal treatment 

_ of pedicle, 533, 536 
indications for, 533 
intra-peritoneal . treatment 

of pedicle, 533, 536 
operation, 534 
statistics of results, 538 
by morcellement, 530 
by myomectomy, 540 
by oophorectomy, 541 
indications, 541 
results as regards diminu- 
tion of tumor, 542 
results as regards hemor- 
rhage, 541 
curative, medicinal, 524 
curative, surgical, 526 
palliative, 523 
varieties, 516 
Fibroma of the breast, 801 
of the ovary, 665 
of the uterus, 512 
Fibromata of the vulva, 127 
Fibrous polypus of the uterus, 517 

tumors of the uterus, 512 
Fissure of the urethra, 238 
Fistula, operation, treatment of sinuses re- 
maining after, 274 
perineo-vaginal, 277 
peritoneo-vaginal, 277 
recto-vaginal, after perineorrhaphy, 208 
urethro-vaginal, 245 
vesico-abdominal, 274 
vesico-uterine, 246 
vesico-utero-vaginal, 246 
vesico-vaginal, 245 
Fistula?, entero- vaginal, 276 
fecal, 274 
causes, 275 
examination for, 276 
physical signs, 275 
prognosis, 275 
symptoms, 275 
treatment, 275 
varieties, 274 
Fistulse of the female genital organs, 245 
causes, 246 
complications, 250 
means of obtaining a natural 
cure, 255 



INDEX. 



815 



Fistula 1 of the female genital organs, phys- 



ical si< 



14!) 



prognosis, 250 
symptoms, 249 
treatment, 255 

by cauterization, 255 
by closure of the vagina, 268 
by elytrorrhaphy, 268 
by episiorrhaphy, 269 
by kolpokleisis, 268 
by Simon's operation, 261 
by Sims's operation, 256 
by suture, 256 
Fistula?, uretero-uterine, 272 
uretero-vaginal, 272 
urinary, 245 

urinary, requiring special treatment, 271 
vaginal, blind, 277 
vaginal, simple, 276 

definition, 276 
vesi co-cervical, 271 
vesico-utero- vaginal, 271 
with extensive destruction of the base 
of the bladder, 272 
Flap-splitting operation for lacerated peri- 
neum, 205 
Flatus vaginalis, 168 

Flexion, acute, of the canal in uterine 
pathology, 49 
of the cervix, etiology, 376 
of the uterus, cervical, corporeal, and 
cervico-corporeal, operation for 
irreducible, 418 
of the uterus, results and complica- 
tions, 373 
Flexions and versions of the uterus, path- 
ological significance of, 359 
relation of uterine ligaments to, 
368 
Flexions of the uterus, exciting causes. 
375 
frequency of, 365 
predisposing causes, 374 
Follicular degeneration of the cervix, 334 
Food, insufficient, as a cause of disease, 44 
Forceps, Emmet's curette, 344 
Goodell's avulsion, 530 
Munde's uterine dressing, 64 
Thomas's dressing, 64 
tooth, 194 
Forms for taking history of patient, 74 
Fossa naviculars, anatomy of, 125 
Fowler's pessary for anterior and posterior 

displacement, 414 
Fungoid degeneration of the endometrium, 

338 
Fungosities, uterine, 338 
causes, 339 

course, duration, and termination, 341 
frequency, 338 
pathology, 339 
physical signs, 339 
prognosis, 3 12 
results, 342 
symptoms, 340 
treatment, 342, 014 



G. 



Galvanism, diseases in which it is in- 
dicated, 106 
Garrulitas vulva?, 168 
Gauze, bichloride, preparation of, 62 
carbolized, preparation of, 62 
iodoform, as tampon, 69 
preparation of, 62 
Gehrung's pessary for cystocele, 177 
General management and hygiene, inatten- 
tion to, a cause of failure in treat- 
ment, 56 
Genu-pectoral position, action in retrover- 
sion, 429 
Germs, their relation to disease, 60 
Gestation, ectopic, 768 
Glands, muciparous, in the vagina, 217 
Glandular vaginitis, 222 
Gonococcus of Neisser, 220 
Gonorrhoea, 220 
Goodell's avulsion forceps, 530 

dilator, 624 
Graafian follicles, formation of, 637, 638 
Granular degeneration of the cervix, 330 
endometritis, 339 
vaginitis, 222 
Gynandria, 122 

Gynecology, historical sketch of, 17 
literary sketch of, 33 

H. 

Hematocele, extra-subperitoneal, 505 
intra-peritoneai, 505 
pelvic, 500 

causes, 503 

course, duration, and termination, 
507 

differentiation, 507 

frequency, 501 

pathology, 501 

physical signs, 506 

prognosis, 508 

symptoms, 504 

treatment, 508 

varieties, 504 
pudendal, 138 

causes, 138 

differentiation, 139 

mode of development, 138 

natural course, 137 

pathology, 13S 

prognosis, 139 

symptoms, 139 

treatment, 139 
retro-uterine, 500 
Hematokolpos, 227 
Hematoma of the ovary, 648 

pelvic, 500 

peri-uterine, 500 
Hematometra, 229 
Hemato-salpinx, 229, 760 
Hair, switch of, from dermoid cyst, 669 
Hard-rubber slick for applications to va- 
gina and cervix. 292 



816 



INDEX. 



Hegar's extra-peritoneal treatment of ped- 
icle, 536 
graduated sounds, 624 
operation, 747 

operation of colporrhaphy, 184 
Hemorrhage, pudendal, 137 
causes, 137 
symptoms, 137 
treatment, 137 
Hemorrhagic endometritis, 339 
Hermaphrodism, 119 
false, 121 
true, 119 
Hernia, entero- vaginal, 175 
of the uterus, 463 
pudendal, 140 

treatment, 141 
recto-vaginal, 174 
vesico-vaginal, 173 
Hernia 3 , vaginal, treatment, 176 
Hewitt's anteversion pessary, 413 

retroversion pessary, 436 
Hilus ovarii of newborn child, 640 
Historical sketch of gynecology, 17 
Hitchcock's pessary for anterior displace- 
ments, 414 
Hodge's closed lever pessary, 433 
Hoffman's soft-rubber pessary, 432 
Hook, Munde's counter-pressure, 259 
Hydrocele, 141 
differentiation, 143 
pathology, 142 
treatment, 143 
Hydrometra, 229 
Hydrops folliculorum, 675 
Hydro-salpinx, 759 

Hygiene, inattention to general manage- 
ment and, a cause of failure in 
treatment, 56 
Hymen, absence of, 21 1 
anatomy of, 125 

anatomy and physiology of, 209 
distensible, 212 
fimbriated, 212 
imperforate, 211 

causing retention of menstrual blood, 
211 
injuries to, 212 
malformations of, 211 
neoplasms of, 213 
unyielding, 212 
varieties of, 210 
with double opening, 212 
Hyperesthesia of the vulva, 150 
Hyperplasia, areolar, of the uterus, 306 
causes, 319 

cervical and corporeal, 317 
complications, 322 
course and termination, 316 
cystic, of the cervix, 335 
differentiation, 321 
frequency, 317 
galvanism in, 106 
in uterine pathology, 51 
of the endometrium, 338 
pathology, 310 



Hyperplasia, areolar, of the uterus, phys- 
ical signs, 320 
prognosis, 322 
symptoms, 319 
treatment, 322 

by amputation of one lip of the 

cervix, 328 
by depletion, 326 
by local alteratives, 328 
by rest, 324 

by vaginal injections, 328 
by wedge-shaped excision, 329 
general, 326 
of complications, 323 
varieties, 317 
Hyperplastic endometritis, 339 
Hypertrophv, diffuse, of the breast, 800 
of clitoris", 126 

of foetal uterus and ovaries, 113 
of labia majora, 126 
of nymphae, 126 
Hysterocele, 463 
Hysterectomy, abdominal, for fibroids, 532 

vaginal, for cancer, 582 
Hysteropexy for retro-displacements, 440 
Hvsterorrhaphy for retro-displacements, 
440 

I. 

Ice-Avater coil as an antipyretic, 70 
Impaction of gravid retroflexed uterus, 

sloughing of bladder from, 243 
Improprieties of dress as a cause of dis- 
ease, 38 
Imprudence after parturition as a cause 
of disease, 40 
during menstruation as a cause of 
disease, 40 
Incision, crucial, of external os, 291 

for dysmenorrhcea or sterility, 627 
Incrustation of the bladder, 242 
Infection, septic, prevention of, 60 
Infecundity, 786 

Inflammation of the broad ligaments, 463 
Inhaler, Clover's ether, 719 
Injections, vaginal, as a therapeutic re- 
source, 64 
author's method, 65 
Emmet's method, 65 
medicated, 67 
nozzle for, 67 
Injuries due to parturition, neglect of, as 

a cause of disease, 42 
Injury as a cause of fistula?, 247 
Inspection in diagnosis, 78 
Instruments, care of, 64 
Insufficient food as a cause of disease, 41 
Interdependence of the various physiolog- 
ical processes, 45 
Internal metritis, 292 

acute, 278 

Interstitial pregnancy, 769 

Intestines, prolapse of, 175 

Intra-ligamentous ovarian cysts, 745 

diagnosis, 745 

treatment, 746 



INDEX. 



817 



Intra-parietal treatment of pedicle, 534 
Intra-peritoneal treatment of pedicle, 536 
Inversion of the uterus, 441 
causes, 445 
complete, 442 

course, duration, and termination, 448 
partial, 442 
pathology, 442 
physical signs, 447 
prognosis, 449 
symptoms, 446 
treatment, 450 

amputation, 459 

elastic pressure by vaginal water- 
bag, 454 
gradual reduction by repositor, 

453 
methods of checking hemorrhage, 

uterus left in situ, 450 
rapid reduction by taxis, 455 
Barrier's method, 456 
Courty's method, 456 
Emmet's method, 456 
Noeggerath's method, 456 
Tate's method, 457 
Thomas's method, 457 
resume of plans, 461 
varieties, 441 
Iodoform gauze as tampon, 69 
Irregular menstruation, 602 
Irremovable ovarian cysts, 744 
Irritable urethra, 238 
urethral caruncle, 151 



K. 



Katharine Hohmann, genital organs of, 120 
Knife, Sims's adjustable uterine, 420 

Studley's probe-pointed, 420 
Knot, Staffordshire, 732 
Kolpokleisis, 268 
Kraurosis of the vulva, 134 



Labia majora, anatomy of, 123 
atrophy of, 127 
hypertrophy of, 1 26 
phlegmonous inflammation of, 135 
Labia minora, anatomy of, 125 
Lacerated cervix, pathological changes in, 

349 
Laceration of the cervix, 345 
bilateral, 348 
diagnosis, 350 

differential, 351 
evil results of, 351 
etiology, 346 
frequency, 348 

its place in uterine pathology, 49 
pathology, 346 
stellate,' 349 
symptoms, 350 
prognosis, 352 
significance, 352 
treatment, 353 



Laceration of the cervix, treatment, opera- 
tive, 354 
palliative, 353 
unilateral, 348 
varieties and degrees, 348 
with cystic and papillary hyperplasia, 
simulating epithelial cancer, 349 
of the perineum, 168. 185 
results of, 188 
varieties, 188 
Lacing, deleterious effects of, 39 
Laminaria tent, 94 
Laparotomy for fibroid tumors, 532 
Latero-flexion of the uterus, 441 
Lefort's operation of colporrhaphy, 184 
Leucorrhoea, cervical, 284 
uterine, 292 
acute, 278 
Levatores ani, importance of integritv of, 

163 
Lichen of the vulva, 134 
Ligaments, broad, anatomy, 782 
cystic tumors of, 783 
diagnosis, 783 
prognosis, 784 
treatment, 784 
diseases of, 782 
solid tumors of, 784 
Ligaments and pelvic fascia, general path- 
ology of, 52 
round, diseases of, 785 
uterine, diseases of, 782 

relation to version and flexion, 367 
utero-vesical and utero- recto-sacral, dis- 
eases of, 785 
diagnosis, 785 
treatment, 785 
Ligatures and sutures, sterilization of, 62 
Lipoma of the breast, 801 
Lupus of the vulva, 128 
Lymphangitis and lymphadenitis, pelvic, 
491 
causes, 492 

course and termination, 492 
diagnosis, 492 
galvanism in, 106 
symptoms, 492 
treatment, 492 

M. 

Malformations of the Fallopian tubes, 753 

of the female sexual organs, congenital 
and infantile, 109 
Mammary glands, diseases o\\ 794 
Manikin figure for teaching diagnosis, 102 
Manipulation, conjoined, in diagnosis, 79 

practice o\\ 80 
Marriage with existing uterine disease as 

a factor in etiology, 43 
Martin's operation of myomectomy, 540 
Mastitis, 796 

diagnosis. 797 

prognosis. 797 

symptoms and course. 797 

treatment, 797 



818 



INDEX. 



Meatus urinarius, examination of, 235 
Meigs's elastic-ring pessary, 436 
Membranous dysmenorrhea, 628 

uterus, 520 
Menopause, 599 
Menorrhagia, 607 
causes, 608 
differentiation, 610 
frequency, 607 
pathology, 608 
prognosis, 611 
treatment, 611 
curative, 613 
palliative, 611 
Menstrual blood, retention of, due to im- 
perforate hymen, 211 
Menstruation and ovulation, connection 
between, 596 
disorders of, 596 

imprudence during, as a cause of dis- 
ease, 40 
irregular, 602 
operations during, 63 
physiology of, 596 
scanty, 602 
suppression of, 600 

causes and treatment, 600 
frequency, 602 
vicarious, 602 
Mercury, bichloride of, as a germicide, 61 
Metalbumin, test for, 678 
Metritis, chronic, a misnomer, 51 
parenchymatous, 306 
internal, 292 
acute, 278 
villous, 339 
Metrorrhagia, 607 
causes, 608 
differentiation, 610 
frequency, 607 
pathology, 608 
prognosis, 611 
treatment, 611 
Microscope in diagnosis, 100 
Mismanagement of the puerperium a fruit- 
ful source of female disease, 168 
Molesworth's cervical dilators, 528 
Monocyst of the ovary, 674 
Muciparous glands in the vagina, 217 
Mucous membrane, cervical, anatomv of, 
284 
membrane of the uterus, anatomv of, 

294 
patch of the cervix, 336 
Mullerian ducts, coalescence of, in a fcetal 

sheep, 110 
Munde's counter-pressure hook, 259 
flanged Sims's speculum, 86 
flat sharp curette, 343 
ovariotomy clamp for searing the ped- 
icle", 731 
uterine dressing-forceps, 64 
vaginal and cervical electrodes, 104 
Myo-fibromata of the uterus, 512 
Myoma of the uterus, 512 
Myomectomy for fibroids, 540 



Myo-sarcoma striocellulare uteri, 548 
Myxo-adenoma of the ovary, 667 



X 



Narrowing or closure of the canal in 

uterine pathology, 50 
Needle, exploring, in diagnosis, 99 

for primary perineorrhaphy, or abdom- 
inal suture after laparotomy, 739 
for vesico-vaginal fistula operation. 739 
Needle-holder, Sims's, 258 
Needles for electro-puncture, 105 
Neglect of exercise and physical develop- 
ment as a cause of disease, 36 
of injuries due to parturition as a cause 
of disease, 42 
Neoplasms of the bladder, 243 

of the vulva, 127 
Nervous system, derangement of, in uterine 
pathology, 50 
excessive development of the, as a 
cause of disease, 37 
Neuralgia, pelvic, galvanism in, 106 
Neuralgic dysmenorrhea, 50, 616 
Neuromata of the vulva, 129 
Nipple, absence of, 796 
eczema of, 796 
Paget's disease of, 796 
retraction of, 796 
Noeggerath on latent gonorrhoea in the 
female sex, 221, 754 
method of replacing inverted uterus, 
456 
of vesico-rectal exploration, 82 
Nott's speculum, 84 

Nozzle, vaginal syringe, with reverse cur- 
rent, 67 
Nympha?, atrophy of, 127 
hypertrophy of, 126 



O. 



Obliteration of the vagina, 269 
Obstructive dysmenorrhcea, 620 
: Oophorectomy, 747 
for fibroids, 541 
indications, 749 
methods of operating, 750 
results, 748 

theory of the operation, 748 
Oophoritis, 652 
acute, 652 

causes, 653 
differentiation, 654 
pathology, 653 
prognosis, 654 
symptoms, 654 
treatment, 654 
chronic, 655 

galvanism in, 106 
physical signs, 657 
prognosis, 657 
symptoms, 656 
treatment, 657 
Operations during menstruation, 63 



INDEX. 



819 



Operations during menstruation, precau- 
tions for the prevention of septic 
infection, 60 
rules to be observed in, 62 
Ovarian cysts and cystoma, 672 
adhesions, 703 
age of occurrence, 681 
aspiration in, 705 
causes, 681 

of death, 689 
conditions likely to complicate, 687 
cancer of uterus, 688 
compression of ureters, 688 
diseases of the kidney, 688 
diseases of the liver, heart, and 

lungs, 688 
elevation of bladder, 689 
fibroids of uterus, 688 
pregnancy, 687 
contents of, 677 
diagnosis, 698 
differentiation, 690 
from ascites, 695 
from cvsts of broad ligament, 

691 
from cysts of omen turn, etc., 694 
from cysts of the spinal cord, 694 
from displaced kidney, 691 
from distended bladder, 695 
from encysted peritoneal drop- 
sy, 692 
from fecal tumor (coprostasis), 

696 
from hydro-sal pinx, 693 
from parasitic cysts, 693 
from pediculated fibroids, 690 
from pregnancy, 695 
from pseudo-cysts, 695 
from renal, hepatic, and splenic 

cysts, 693 
from solid tumors of the spleen, 

691 
from tubercular peritonitis, 694 
from tumors of anterior ab- 
dominal wall (desmoids), 691 
from uterine fibro-cysts, 692 
duration, 683 
explorative incision, 706 
intraligamentous, 745 
irremovable, 744 

morbid conditions liable to occur, 684 
inflammation and suppuration, 

684 
intracystic hemorrhage, 686 
peritonitis and adhesions, 684 
rupture of cyst, 686 
twisting of pedicle, 685 
natural history, 682 
pathology, 672 
pedicle, 704 
physical signs, 697 
spontaneous cures, 683 
symptoms, 696 

tapping through abdominal wall. 706 
tapping through vaginal wall, 706 
treatment, 707 



Ovarian disease, varieties of, 641 
dysmenorrhea, 632 

fluids, microscopical appearance of, 678 
tumors, 660 
tumors, solid, 746 
tumors, varieties, 661 
Ovaries, absence of, 642 
absent or rudimentary, 117 
anatomy, 638 

and tubes, general pathology of, 51 
atrophy of, 647 
causes, 647 
treatment, 648 
diseases of, 636 
displacement of, 650 
diagnosis, 651 
symptoms, 651 
treatment, 651 
imperfect development of, 642 

treatment, 644 
irregular development of, 645 
Ovariotomy, 708 
abdominal, 717 

anaesthetic, 719 

assistants, 721 

incision, 723 

instruments, sponges, gauzes, etc., 

720 _ 
operating-room, 719 
operating-table, 721 
operation, steps of, 725 
position of patient, operator, assist- 
ants, etc., 723 
preparatory treatment, 717 
after-treatment, 739 

clamp for searing pedicle, Munde's, 731 
cleansing the peritoneum, 734 
closing the wound, 738 
conditions favorable to, 715 

unfavorable to, 717 
dangers, 713 

establishing drainage, 734 
dangers, 737 
indications, 734 
methods, 736 
evils after the operation, 743 
removal of the sac, 729 
securing the pedicle, 730 
statistics, 713 
tapping the cyst, 727 
varieties, 713 
Ovaritis, 652 
Ovary, abscess of, 658 
diagnosis, 659 
frequency, 659 
pathology, 659 
treatment, 660 
accessory, 644 

apoplexy or hematoma of, 648 
diagnosis, 649 
prognosis, 649 
symptoms, 649 
treatment, C^O 
carcinoma o\\ 662 
diagnosis, 663 
differentiation, 663 



820 



IXDEX. 



Ovary, carcinoma of, symptoms, 663 
varieties, 662 
constricted, 646 

cystic degeneration of a constricted por- 
tion, 646 
cysto-carcinoma of, 666 
cysto-fibroma of. 667 
cysto-papilloma of, 667 
cysto-sarcoma of, 667 
dermoid cysts of, 667 
division of, 645 
fibro-cyst of, 665 
fibroma of, 665 
myxo-adenoma of, 667 
of new-born child, hilus of, 640 
papilloma of, 664 
sarcoma of, 664 
Overwork of brain as a cause of disease, 

37 
Ovulation and menstruation, connection 
between, 596 



P. 



Pachysalpingitis, 756 

galvanism in, 106 
Pad, suprapubic, 410 
Paget's disease of the nipple, 796 
Palmer's dilator, 624 

Palpation, abdominal, conjoined with the 
use of the sound in diagnosis, 81 
in diagnosis, 80, 81 

bimanual, in diagnosis, 79 

of the ureters, 236 
Papillary vaginitis, 222 
Papilloma of the Fallopian tube, 768 

of the ovary, 664 
Papillomata of the vulva, 127 
Papular vaginitis, 222 
Paquelin's thermo-cautery, 153 
Paralbumin, test for, 678 
Parametritis, 463 
Para-uterine cellulitis, 463. 
Parenchymatous metritis, chronic, 306 
Parturition, imprudence after, as a cause 
of disease, 40 

neglect of injuries due to, as a cause of 
disease, 42 
Pean's extra-peritoneal treatment of pedi- 
cle, 536 
Pedicle, extra-peritoneal, treatment of, 536 

intra-parietal, treatment of, 534 

intra-peritoneal, treatment of, 536 
Pelvic abscess, 464, 493 

cavity, diagram of, 480 

cellular tissue, sarcoma of, 561 

cellulitis, 463 

fascia and ligaments, general pathologv 
of, 52 

hematocele, 500 

lymphangitis and lymphadenitis, 491 

neuralgia, galvanism in, 106 

organs, normal relations of. diagram of, 
363 

organs, normal topography of female, '■ 
612 



Pelvic organs with distended bladder, 
obo 
organs with distended rectum, 364 
outlet, vertical transverse section of the 

soft parts at the, 161 
peritoneum, diagram of, 479 
peritonitis, 475 
Pelvis, bloody tumor of, 500 
cross-section of, 468 
roof of, diagram of, 478 
Percussion in diagnosis, 101 
Perineal body, 160 
Perineal laceration, causes, 189 
natural history of, 190 
prognosis, 189* 
results of, 188 
suturing when fresh, 192 
time for operation, 190 
treatment of cicatrized cases, 193 
varieties, 188 
Perineorrhaphy, 193 

Cleveland's suture for, 208 
diagram of surfaces to be denuded, 197 
Emmet's new operation, 204 
flap-splitting operation, 205 
for complete rupture, 200 
for partial rupture, 195 
for prolapsus, 398 

instruments and appliances needed, 194 
preparation of patient, 194 
recto-vaginal fistula after, 208 
rules of practice, 203 
secondary, dangers and ill results of, 208 
Simon's method, 203 
varieties of sutures used in, 209 
Perineo-vaginal fistula, 277 
Perineum, anatomy, 160, 185 
atony, causes, 166 
diagram ordinarily used for representing, 

162 
effects following its removal, 165, 187, 

411 
functions, 163 

importance to the obstetrician, 168 
lacerated, result of improper repair, 187 

surgical repair of, 185 
laceration of, 168, 185 

importance of early repair, 170 
results of, 169 
pathology, 160 
physiology, 160 
rupture of, 168, 185 

schematic diagrams of, 164, 186, 187, 411 
Peritoneo-vaginal fistula, 277 
Peritoneum, general pathology of, 52 

pelvic, diagram of, 479 
Peritonitis, pelvic, 475 
causes, 480 
course, duration, and termination, 

485 
differentiation, 485 
frequency, 478 
galvanism in, 106 
pathology, 479 
physical signs, 484 
prognosis, 487 



INDEX. 



821 



Peritonitis, results, 487 
symptoms, 482 
topography, 474 
treatment," 487 

evacuation, question of, 491 
methods of, 491 
of chronic cases, 490 
varieties, 482 
Peri-uterine hematoma, 500 

phlegmon, 463 
Pessaries for anterior displacements of the 
uterus, 412 
for prolapsus uteri, 395 
prejudice against, 55 
rules for patients, 60 
use and abuse of, 58 
Pessary, Albert H. Smith's, 434 
cup, 418 
Cutter's, 437 

Cutter's prolapsus, 396, 397 
elastic bulb, 435 
for cystocele, Gehrung's, 177 
Fowler's, for anterior and posterior dis- 
placements, 414 
Graily Hewitt's anteversion, 413 
Hewitt's retroversion, 436 
Hitchcock's, for anterior displacements, 

414 
Hodge's closed lever, 433 
Hoffman's soft-rubber, 432 
intra-uterine, 416 
Meigs's elastic ring, 436 
retroflexion, with cervical rest, 439 
stem, 416 

Thomas's anteversion, 412 
Thomas's elastic, for anterior displace- 
ments, 413 
Thomas's modification of Cutter's prolap- 
sus, 397 
Thomas's retroflexion, 434 
Phenacetin as an antipyretic, 70 
Phlegmon, peri-uterine, 463 
Phlegmonous inflammation of the labia 
majora, 135 
diagnosis, 136 
symptoms, 136 
treatment, 136 
Physical development, neglected, as a cause 
of disease, 36 
diagnosis, 87 
Physiological processes, interdependence 

of the various, 45 
Physometra, 229 
Polymazia, 795 
Polypi of the bladder, 243 
uterine, 546 
fibrous, 517, 551 

course and termination, 554 
differential diagnosis, 553 
pathological anatomy, 551 
physical signs, 552 
prognosis, 554 
symptoms, 552 
treatment, 55 I 
glandular, 517 

course and termination, 549 



Polypi of the bladder, glandular, patholog- 
ical anatomy, 547 
physical signs, 549 
prognosis, 549 
symptoms, 549 
treatment, 549 
Polypoid endometritis, 339 
Polypus, mucous, occluding tubal opening, 

790 
Position, genu-pectoral, action in retrover- 
sion, 429 
incorrect, of patient in examining with 

Sims's speculum, 89 
of patient, physician, and nurse during 
an examination with Sims's specu- 
lum, 88 
Simon's, for vesico-vaginal fistula opera- 
tion, 90 
Potain's aspirator, 99 
Precautions for catheterization, 64 

to prevent septic infection in opera- 
tions, 60 
Predisposing causes of disease in the fe- 
male, 35 
Pregnancy, extra-uterine, 768 
Pressure as a cause of fistula?, 246 
Prevention of conception as a cause of dis- 
ease, 42 
Probing the uterus, mode of, 92 
Prognosis, erroneous, a cause of failure in 
treatment, 54 
in uterine affections, 52 
Prolapse of the bladder, 173 
of the intestines, 175 
of the rectum, 174 
Prolapsus of the uterus, 378 
anatomy, 378 
causes, 379 
complications, 388 
course, duration, and termination, 

386 _ 
definition, svnonyms, and frequency, 

378 
diagram of the uterine axis in the 

three degrees of, 379 
differentiation, 387 
due to atony of perineum, 167 
due to senile atrophy, 167 
frequency, 381 
pathology, 381 
pessaries for, 395 
physical signs, 387 
prognosis, 387 
recumbent posture in. 393 
sudden or acute, 38 ; 
symptoms, 336 
treatment. 389 

means tor preventing traction 

by the vagina, 397 
methods of replacing the 

uterus. 389 
sustaining the uterus. 390 
perineal support. 398 
perineorrhaphy. 39S 
use o\' astringents and tonics 
in. 393 



822 



INDEX. 



Prolapsus of the uterus, varieties, 379 
of the vagina, 170 
urethrse, 154 

treatment, 155 
Prurigo of the vulva, 134 
Pruritus vulvae, 143 
causes, 144 

mode of development and course, 143 
pathology, 143 
treatment, 146 
Psorolytrie, 222 
Pudendal hematocele, 138 
hemorrhage, 137 
causes, 137 
symptoms, 137 
treatment, 137 
hernia, 140 
Pvokoipos, 227 
Pyometra, 227, 229 
Pyo-salpinx, 7(51 
prognosis, 762 
treatment, 763 

K. 

Eational signs, their value in diagnosis, 73 
Recamier's curette, 343 
Rectocele, 174 

with gaping vaginal orifice, 789 
Recto-vaginal fistula after perineorrhaphv, 
208 
hernia, 174 
Rectum, digital eversion of the, in dia- 
gnosis, 82 
exploration by the introduction of the 

whole hand into the, 81 
prolapse of, 174 
Recumbent posture in prolapsus, 393 
Regions of the abdomen, 362 
Repositor, Sims's uterine, 429 
Repositors for replacing inverted uterus. 

453, 458 
Retention of menstrual blood due to im- 
perforate hymen, 211 
of menstrual blood, etc., within the gen- 
ital tract, 225 
Retroflexion of the uterus from anterior 
fixation of the cervix, 370 
less frequent than anteflexion, 365 
Retro-uterine hematocele, 500 
Retroversion and retroflexion of the uterus, 
422 
consequences, 426 
degrees of, 425 
differentiation, 426 
exciting causes, 422 
frequency, 427 
manual reposition, 439 
physical signs, 425 
predisposing causes, 422 
prognosis, 427 
symptoms, 425 
treatment, 427 

by operation, 440 

Alexander's, 440 
hysteropexy, 440 



Retroversion and retroflexion of the uterus, 
treatment by hystarorrhaphy, 440 
ventro-fixation, 440 
by pessaries, 432 
by tampons, 431 
means for retaining uterus in 

position, 430 
methods of reduction, 427 
varieties, 425 
Roof of the pelvis, diagram of, 478 
Rubber cot for controlling temperature, 69 

tissue, sterilizing, 63 
Rules govering the use of tents, 97 
to be observed in operations, 62 
Rupture of tbe bulbs of the vestibule, 136 
of the perineum, 168, 185 

S. 

Salpingitis, catarrhal, 753 
Sarcoma of the breast, 802 
of the ovary, 664 
of the pelvic cellular tissue, 561 
of the uterus, 558 
causes, 559 
course, duration, and termination, 

560 
differentiation, 500 
frequency, 559 
history, 558 
pathology, 559 
physical signs, 560 
prognosis, 560 
symptoms, 559 
treatment, 561 
of the vulva, 128 
Scanty menstruation, 602 
Scarificator, spear-pointed, 327 
Schroeder's intra-peritoneal treatment of 

pedicle, 536 
Scirrhus, carcinoma, microscopical appear- 
ance, 570 
of the cervix, 565 
Scissors, curved, 194, 195, 256 

Emmet's, 195 
Sclerosis of the uterus, 316 
Sea-tangle tents, preparation of, 94 
Senile endometritis, 298 
Septic infection, precautions for preven- 
tion of, 60 
Shield for twisting wire sutures, 259 
Signs, rational, their value in diagnosis, 73 
Silk, preparation of, 62 
Silkworm gut, preparation of, 62 
Simon's operation of perineorrhaphy, 203 
for urinary fistula, 261 
position for vesico-vaginal fistula opera- 
tion, 90, 263 
specula, 89 
Sims's adjustable uterine knife, 420 
catheter, new style, 261 
depressor, 85 
needle-holder, 258 
operation for urinary fistula, 256 
operation of colporrhaphy, 179 
sigmoid catheter, 261 



INDEX. 



823 



Sims's speculum, 85 

and its varieties, introduction of, 87 
position of patient, physician, and 
nurse during an examination 
with, 88 
sponge-holder, 257 
steel curette, 343 
tenaculum, 85 
uterine repositor, 429 
Sinuses, capillary, remaining after fistula 

operations, treatment of, 274 
Skene's self-retaining catheter, 262 
Skirt supporter, 392 
Slide applicator for tamponade of uterus, 

306 ■ 
Sloughing of the mucous membrane of the 
bladder from impaction of the 
gravid retroflexed uterus, 243 
Smith's pessary, 434 

Sound, conjoined with abdominal palpa- 
tion in diagnosis, 81 
use among the ancients, 23 
uterine, facts ascertained by, 92 
in diagnosis, 90 

precautions and dangers in the use 
of, 91 
Sounding of the Fallopian tubes, 756 
Sounds, Hegar's graduated, 624 

of Simpson and Sims compared, 92 
Specific vaginitis, 220 
Specula, ancient valvular, 22 

method of introducing valvular and 

cylindrical, 86 
Simon's, 89 

vaginal, varieties of, 83 
Speculum, Brewer's trivalve, 84 
Cleveland's self-retaining Sims's, 87 
Fergusson's, 83 
Munde's flanged Sims's, 86 
Nott's, 84 
Sims's, 85 

and its varieties, introduction of, 87 
position of patient, physician, and 
nurse during an examination 
with, 88 
vaginal, in diagnosis, 83 
Sphincter ani, ruptured, diagrammatic rep- 
resentation of union of, 200 
Sponge-holder, Sims's, 257 
Sponge tent, 94 
Sponges, sterilizing, 63 
Spoon-saw, Thomas's, 531 
Staffordshire knot, 732 
Stem pessary, 416 

precautions and dangers, 417 
Stenosis of the uterus, 229 

of the vagina, 226 
Sterility, 786 
causes, 786 
differentiation, 790 
due to aggravated flexion of the uterus, 

373 • 
prognosis, 791 
results, 791 
treatment, 792 
treatment among the ancients, 23 



Stoltz's operation for cystocele, 1 82 
Stone in the bladder, 242 
Stricture of the urethra, 239 
vaginal, treatment of, 627 
Studley's probe-pointed knife, 420 
Subinvolution a cause of areolar hyper- 
plasia, 313 
as a cause of disease, 41 
as a cause of prolapse of pelvic organs, 

167 
as a consequence of perineal laceration, 

189 
endometritis of, 278 
in uterine pathology, 49 
pathology of, 312 
Sublimate corrosive, as a germicide, 61 
Superficial cancer of the cervix, 564 
Supporter, abdominal, 411 
Suppressio mensium, 600 
Sutures and ligatures, sterilization of, 
62 
shield for twisting wire, 259 
shouldering, 260 
Syphilis of the vulva, 135 
Syphilitic ulcer of the cervix, 336 
course and termination, 337 
differentiation, 337 
treatment, 338 
Syringe, Davidson's, 6Q 
mucus, 292 



Table, Thomas's gynecological, 76 
Tables for examination, 76 
Tampon as a hemostatic, 68 

iodoform gauze, 69 

mode of introduction, 68 

removal of, 68 

as a therapeutic resource, 67 
Tampons, application for retroversion, 

431 
Tate's method of replacing inverted ute- 
rus, 557 
Taxis for replacing inverted uterus, 455 
Telangiectatic tumors of the uterus, 514 
Temperature, means for control, after 
operations and during patholog- 
ical conditions, 69 

control by antipyretics, 70 

control by ice-water coil, 70 

control by the cold wet sheet, 70 
Tenaculum, Sims's, 85 
Tent, laminaria, 94 

sponge, 94 

spring, Ellerslie Wallace's, 409 

tupelo, 94 
Tents, comparative advantages o( sponge, 
laminaria, and tupelo. 95 

dangers in their use, 90 

in diagnosis, 93 

mode of introducing, 90 

rules governing the use of, 97 

sea-tangle, preparation of. 9! 
Therapeutic resources of gynecology, the 
most important. 57 



824 



IXDEX. 



Therapeutics, inefficient or inappropriate, 
a cause of failure in treatment, 54 
Therm o-cautery, Paquelin's, 153 
Thiersch's solution, composition of, 61 
Thomas's anteversion pessary. 413 

dressing-forceps, 64 

dull wire curette, 343 

elastic pessary for anterior displace- 
ment, 413 

gynecological table, 76 

method of replacing inverted uterus. 
457 

modification of Cutter's prolapsus pes- 
sary, 397 

retroflexion pessary, 434 

spoon-saw, 531 

tooth-forceps, 194 
Tight bandaging after parturition as a 
cause of disease, 41 

clothing as cause of disease, 38 
Tooth-forceps, Thomas's. 194 
Topography, normal, of the female pelvic 

organs, 162 
Touch, double, 82 

vaginal, in diagnosis, 78 
performance of, 78 
Trachelorrhaphy, assistants required for, 
354 

dangers of, 357 

diagrams illustrating, 350, 355, 356 

indications for, 353 

instruments required for, 354 

mode of operation, 354 

outline of denuded surface in, 350 

preparation of the patient, 354 

results achieved by, 356 
Trocar and canula. Emmet's, 728 
Tubal pregnancy, 769 
Tuberculosis of the Fallopian tubes. 767 
Tubes, Fallopian, 751 

Tumors, benign or malignant, in uterine 
pathology, 49 

ovarian, 660 
Tupelo tent, 94 
Twisting-tongs. Emmet's, 261 



Ulcers, syphilitic, of the cervix, 336 
Ulceration as a cause of fistula?, 248 

of the cervix, 329, 350 
Ureteritis, 244 
Uretero-uterine fistula?. 272 
Uretero-vaginal fistula?, 272 
Ureters, anatomy of the. 244 

palpation of the. 236 

diseases of the, 236 

fissure of the, 238 

irritable, 238 

prolapse of, 154 
treatment, 155 

stricture of the, 239 
Urethral caruncle, irritable, 151 

venous angioma, 154 
Urethritis, 236 

treatment, 237 



Urethrocele, 237 
cause, 238 

differential diagnosis, 237 
symptoms, 238 
treatment, 238 
Urethro- vaginal fistula, 245 
Urinary fistula?, 245 
Uterine affections, prognosis in, 52 

affections, reasons for failure in the treat- 
ment of, 53 
axis, diagram of, in the three degrees of 

prolapsus, 379 
catarrh, 292 

acute, 278 
development, anomalies of, 118 
disease, marriage with existing, as a fac- 
tor in etiology, 43 
displacement a common cause of subin- 
volution. 41 
dressing-forceps. Munde's, 64 
fibroids, 512 
fungosities, 338 
leucorrhoea, 292 

acute. 27 S 
ligaments, diseases of, 782 

relation to version and flexion, 368 
mucous membrane, fungous degenera- 
tion of, treatment, 614 
pathology and treatment, general con- 
siderations upon, 47 
polypi. 546 
sound in diagnosis, 90 
! Uterus, absence of, 113 
adenoma of the. 556 
and appendages in youth, front view. 
Ill 

rear view, 112 
and ovaries, foetal, hypertrophy of, 113 
anteflexion more frequent than retro- 
flexion, 365 
anteflexion of the, 404 
anteversion of the. 400 
areolar hyperplasia of the, 306. 
ascent of the, 377 
atresia of the. 229 

causes, 229 

diagnosis and differentiation, 230 

prognosis. 230 

results, 229 

treatment. 231 

varieties, 229 
bicorn, 116 
cancer of the, 562 
congenital misplacement of. 117 
descent of the, 378 
displacements of the, 358 
divided, 117 
double. 117 

fibro-cystic tumors of the, 543 
fibroid tumors of the, 512 
fibroma of, 512 
fibrous polypus of, 317 

tumors of, 512 
flexions of the, exciting causes, 375 

frequencv of. 365 

hernia of, 463 



INDEX. 



825 



Uterus, flexions of the, predisposing causes, 
374 
results and complications, 373 

hyperplasia of, galvanism in, 106 

impaction of the gravid retroflexed, 
sloughing of the raucous mem- 
brane of the bladder from, 243 

inversion of the, 441 

latero-flexion of the, 441 

mechanical influences which sustain, 361 

membranous, 520 

mode of probing, 92 

mucous membrane of the, anatomy of, 294 

myo-fibromata of, 512 

myoma of the, 512 

normal position in a parous woman, 367 

normal position of the virgin, 367 

pathological anteflexion of, from short- 
ening of the sacro-uterine ^lig- 
aments, 369 

pathology of the, 48 

posterior displacements of the, 422 

prevention of pressure from above, 391 
prolapse of, due to atony of peri- 
neum, 167 
due to senile atrophy, 167 

prolapsus of the, 378 

diminution of uterine weight, 392 

retroflexion of, from anterior fixation 
of the cervix, diagram of, 370 

retroposed and anteflexed, a frequent 
cause of sterility, 790 

retroversion and retroflexion of the, 420 

rudimentary development of, 113 

rudimentary, examination for, 115 

sarcoma of the, 558 

septus. 117 

sclerosis of, 316 

slight anteflexion normal, 366 

stenosis of the, 229 

strengthening or supplementing its 
supports, 393 

telangiectatic tumors of, 514 

unicorn, 116 

versions and flexions of, pathological 
significance of, 359 
relation of uterine ligaments to, 368 

V. 

Vagina, absence of the, 231 
absent or rudimentary, 118 
anatomy of the, 216 
atresia of the, 226 

causes, 227 

pathology, 226 

physical signs, 227 

prognosis, 228 

results, 227 

symptoms, 227 

treatment, 231 

varieties, 226 
closure of the, 268 
columns of the, 217 
microscopical section through, 216 
muciparous glands in, 217 



Vagina, obliteration of the, 269 
prolapsus of, 170 
causes, 172 

course and duration, 173 
pathology, 171 
prognosis, 173 
symptoms, 173 
varieties, 172 
treatment, 176 
short, 118 
stenosis of the, 226 
Vaginal cysts, 235 
fistnlae, blind, 277 

simple, 276 
hernias, treatment, 176 
hysterectomy for cancer, 582 
injections as a therapeutic resource, 64 
author's method, 65 
Emmet's method, 65 
medicated, 67 
nozzle for, 67 
specula, varieties of, 83 
speculum in diagnosis, 83 
stricture, treatment of, 627 
touch in diagnosis, 78 
performance of, 78 
Vaginismus, 213 
treatment, 214 
Vaginitis, 216 
adhesive, 217 
epithelium in, 219 
glandular, 222 
granular, 222 
causes, 224 
pathology, 222 
symptoms, 224 
treatment, 224 
papillary, 222 
papular, 222 
senile, 217 
simple, 217 

causes, 218 
complications, 219 
differentiation, 219 
pathology, 218 
physical signs, 219 
prognosis, 219 
symptoms, 218 
treatment, 224 
varieties, 217 
specific, 220 
causes, 220 
complications, 222 
course, duration, termination, 221 
definition, 220 
differentiation, 220 
pathology, 220 
physical signs, 220 
symptoms, 220 
treatment, 224 
varieties of, 217 
Veins of the vestibule. 136 
Venereal warts, treatment of, 127 
Venous angioma, urethral. 154 
Yentro-tixation for retro-displacements 
440 



826 



INDEX. 



Versions and flexions of the uterus, path- 
ological significance of, 359 
relation of uterine ligaments to, 
368 
Vesical calculus, 242 
Vesico-abdominal fistula, 274 
Vesico-cervical fistula 3 , 271 
Vesico-rectal exploration in diagnosis, 82 

Noeggerath's method, 82 
Vesico-uterine fistula, 246 
Vesico-utero-vaginal fistula, 246, 271 
Vesico-vaginal fistula, 245 

hernia, 173 
Vestibule, anatomy of, 125 
rupture of the bulbs of, 136 
veins of, 136 
Vicarious menstruation, 602 
Villous endometritis, 557 

metritis, internal, 339 
Vulva, acne of, 135 
anatomy of, 123 
cancer of, 128 
condylomata of, 127 
deformities of, 126 
diseases of, 123 
eczema of, 134 
elephantiasis of, 128, 135 
eruptive diseases of, 134 
erysipelas of, 135 
erythema of, 135 
fibromata of, 127 
Vulva, hyperesthesia of, 150 
causes, 150 
differentiation, 150 
frequency, 150 
pathology, 150 
symptoms, 150 
treatment, 151 
kraurosis of, 134 
lichen of, 134 
lupus of, 128 
neoplasms of, 127 
neuromata of, 129 
of married nullipara, 124 



Vulva of multipara, 789 
of virgin, 123 
papillomata, of, 127 
parous, diagram of, 380 
prurigo of, 134 
pruritus of, 143 
sarcoma of, 128 
syphilis of, 135 
Vulvitis, 129 
adhesive, 131 
follicular, 132 

causes, 132 

course and duration, 133 

definition, 132 

physical signs, 133 

symptoms, 132 

treatment, 133 
purulent, 130 

causes, 130 

course and termination, 131 

symptoms, 130 

treatment, 131 
simple, 129 
Vulvo-vaginal glands, cyst and abscess of, 
155 

causes, 155 

course and duration, 156 

differentiation, 156 

symptoms, 155 

treatment, 156 



W. 

Waist for support of skirts, 392 
Warts, venereal, treatment of, 127 
Water-bag, vaginal, for replacing inverted 

uterus, 454 
Water, stream of cold, for replacing in- 
verted uterus, 454 
Wet cold sheet as an antipyretic, 70 
White's method of replacing inverted 

uterus, 449 
Woelfler-Hacker's intra-parietal treatment 
of pedicle, 534 



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The arrangement of this volume in the form of question and answer renders it espe- 
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HOBLYN, BICHABD D. 9 M. D. 

A Dictionary of the Terms Used in Medicine and the Collateral 
Sciences. Revised, with numerous additions, by Isaac Hays, M. D., hue editor of 
The American Journal of the Medical Sciences. In one large royal 12mo. volume ot 520 
double-columned pages. Cloth, $1.50; leather, $2.00. 

It is the best book of definitions we have, and ought always to be upon the student's table — •>. 
Medical a>>d Surnical Journal. 



4 Lea Brothers & Co.'s Purifications — Dictionaries. 

THE STANDARD. 

THE 

DATIOnAL IDgDI(£AL DiGTionw 

INCLUDING 

English, French, German, Italian and Latin Technical Terms used in Medicine and 
the Collateral Sciences, and a Series of Tables of Useful Data." 

BY 

John $. BOling?, ty.D., LL.D, Ediq. and Hafir., D.U.L, O^oi). 

Member of the National Academy of Sciences, Surgeon V. S. A., etc. 

WITH THE COLLABORATION OF 

Prof. W. O. ATWATER. JAMES 31. FLINT, M. D., WASHINGTON 31 ATTHEWS, M.D.. 

FRA.NK BAXER, M. D., J. H. KIDDER, 31. D., C. S. 3IINOT, 31. D. 

S. 31. BURNETT, 31. D., WILLIAM LEE, 31. D., H. C. YARROW, 31. D., 

W. T. COUNCIL3IAN, 31. D., R. LORINI, 31. D., 

In two very handsome royal octavo volumes containing 1574 pages, 
with, two colored plates. 

Per Volume— Cloth, $6; JOeatJier, $7; Sal f Morocco, Marbled Edges, $8.50. For Sale 
by Subscription only. Specimen pages on application. Address the Publishers. 



The publishers have great pleasure in presenting to the profession a new practical 
working dictionary embracing in one alphabet all current terms used in every depart- 
ment of medicine in the five great languages constituting modern medical literature. 

For the vast and complex labor involved in such an undertaking no one better quali- 
fied than Dr. Billings could have been selected. He has planned the work, chosen the 
most accomplished men to assist him in special departments, and personally supervised 
and combined their work into a consistent and uniform whole. 

Special care has been taken to render the definitions clear, sharp and concise. 
They are given in English, with synonyms in French, German and Italian of the more- 
important words in English and Latin. 

Eegarded as a dictionary, therefore, this standard work supplies the physician, 
surgeon and specialist with all information concerning medical words, simple and com- 
pound, found in English, giving correct spelling, clear, sharp definitions and accentua- 
tion, and furthermore it enables him to consult foreign works and to understand the large 
and increasing number of foreign words used in medical English. It is especially full 
in phrases comprising two, three or more words used in special senses in the various 
departments of medicine. 

The work is, however, far more than a dictionary, and partakes of the nature of an 
encyclopaedia, as it gives in its body a large amount of valuable therapeutical and chemi- 
cal information, and groups in its tables, in a condensed and convenient form, a vast 
amount of important data which will be consulted daily by all in active practice. 

The completeness of the work is made evident by the fact that it defines 84,844- 
separate words and phrases. 

The type has been most carefully selected for boldness and clearness, and everything 
has been done to secure ease, rapidity and durability in use. 

Its scope is one which will at once satisfy the | three modern continental languages which are 
student and meet ail the requirements of the med- \ richest in medical literature. To add to its use- 
ical practitioner. Clear and comprehensive defi- | fulness as a work of reference some valuable 
nitions of words should form the prime feature of i tables are given. Another feature of the work is- 
any dictionary, and in this one the chief aim the accuracy of its definitions, all of which have 
seems to be to give the exact signification and the i been checked by comparison with many other 
different meanings of terms in use in medicine j standard works in the different languages it deals- 
and the collateral sciences in language as terse as with. Apart from tne boundless stores of informa- 
is compatible with lucidity. The utmost brevity ! tion which may be gained by the study of a good 
and conciseness have been kept in view. The work | dictionarv, one is enabled by the work under notice 
is remarkable, too, for its fulness. The enumera- j to read intelligently any technical treatise in any 
tions and subdivisions under each word heading of the four chief modern languages. There can- 
are strikingly complete, as regards alike the Eng- ! not be two opinions as to the great value and use- 
lish tongue and the languages chiefly employed I fulness of this dictionarv as a book of ready refer- 
by ancient and modern science. It is impossible i ence for all sorts and conditions of medical men. 
to do justice to the dictionary by any casual illus So far as we have been able to see, no subject has 



tration. It presents to the English reader 
thoroughly scientific mode of acquiring a rich 
vocabulary and offers an accurate and ready means 
of reference in consulting works in any of the 



been omitted , and in respect of completeness it will 
be found distinctlv superior to any medical lexicon 
yet published.— The London Lancet, April 5, 1890. 



Lea Brothers & Co.'s Publications — Anatomy. 5 

GHAT, HENRY, F. B. S. 9 

Lecturer on Anatomy at St. George's Hospital, London. 

Anatomy, Descriptive and Surgical. Edited by T. Pickering Pick, 
F. R. C. S., Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, 
Examiner in Anatomy, Royal College of Surgeons of England. A new American from 
the eleventh enlarged and improved London edition, thoroughly revised and re-edited 
by William W. Keen, M. D., Professor of Surgery in the Jefferson Medical College of 
Philadelphia. To which is added the second American from the latest English edition of 
Landmarks, Medical and Surgical, by Luther Holden, F. R. C; S. In one imperial 
octavo volume of 1098 pages, with 685 large and elaborate engravings on wood. Price of 
edition in black: Cloth, $6; leather, $7 ; half Russia, $7.50. Price of edition in colors 
(see below): Cloth, $7.25; leather, $8.25 ; half Russia, $8.75. 

This work covers a more extended range of subjects than is customary in the ordinary 
text-books, giving not only the details necessary for the student, but also the application of 
those details to the practice of medicine and surgery. It thus forms both a guide for the 
learner and an admirable work of reference for the active practitioner. The engravings 
form a special feature of the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in 
place of figures of reference with descriptions at the foot. In this edition a new departure 
has been taken by the issue of the work with the arteries, veins and nerves distinguished 
by different colors. The engravings thus form a complete and splendid series, which will 
greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh 
the memory of those who may find in the exigencies of practice the necessity of recall- 
ing the details of the dissecting-room. Combining, as it does, a complete Atlas of 
Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, 
the work will be found of great service to all physicians who receive students in their 
offices, relieving both preceptor and pupil of much labor in laying the groundwork of a 
thorough medical education. 

For the convenience of those who prefer not to pay the slight increase in cost necessi- 
tated by the use of colors, the volume is published also in black alone, and maintained 
in this style at the price of former editions, notwithstanding its largely increased size. 

Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, 
has been appended to the present edition as it was to the previous one. This work gives 
in a clear, condensed and systematic way all the information by which the practitioner can 
determine from the external surface of the body the position of internal parts. Thus 
complete, the work will furnish all the assistance that can be rendered by type and 
illustration in anatomical study. v 



The most popular work on anatomy ever written. 
It is sufficient to say of it that this edition, thanks 
to its American editor, surpasses all other edi- 
tions —Jour, if the Amer. Med. Ass'n, Dec. 31, 1887. 

A work which for more than twenty years has 
had the lead of all other text-books on anatomy 
throughout the civilized world comes to hand in 
such beauty of execution and accuracy of text 
and illustration as more than to make good the 
large promise of the prospectus. It would be in- 
deed difficult to name a feature wherein the pres- 
ent American edition of Gray could be mended 
or bettered, and it needs no prophet to see that 
the royal work is destined for many years to come 
to hold the first place among anatomical text- 



books. The work is published with black and 
colored plates. It is a marvel of book-making. — 
American Practitioner and News, Jan. 21, 1888. 

Gray's Anatomy is the most magnificent work 
upon anatomy which has ever been published in 
the English or any other language.— Cincinnati 
Medical News, Nov. 1887. 

As the book now goes to the purchaser he is re- 
ceiving the best work on anatomy that is published 
in any language. — Virginia Med. Monthly, Dec. 1887. 

Gray's standard Anatomy has been and will be 
for years the text-book for students. The book 
needs only to be examined to be perfectly under- 
stood.— Medical Press </ Western New York, Jan. 



Also for sale separate — 
HOLDEW, LTJTHEB, E. B. C. $., 

Surgeon to St. Bartholomew's and the Foundling Hospitals, London. 

Landmarks, Medical and Surgical. Second American from the latest revised 
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in 
thePenna. Academy of Fine Arts. In one 12uio. volume of 14S pages. Cloth, $1.00. 



DTJNGLISQir, BOBLEY, M.JD., 

Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. 

MEDICAL LEXICON ; A Dictionary of Medical Science : Containing 
a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- 
ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics. Medical Juris- 
prudence and Dentistry, Notices of Climate and of Mineral Waters, Formula* for Officinal, 
Empirical and Dietetic Preparations, with the Accentuation and Etymology of the Terms, 
and the French and other Synonymes, so as to constitute a French as well as an English 
Medical Lexicon. Edited by Richard J. Dunglison, M. D. In one very large and 
handsome royal octavo volume^of 1139 pages. Cloth, $6.50; leather, raised bands. \ 
very handsome half Russia, raised bands, $8.00. 

It has the rare merit that it certainly has no rival in the English language for accuracy 
and extent of references. — London Meaical Gazette. 



6 



Lea Brothers & Co.'s Publications — Anatomy. 



ALLEN, MABBISON, M. JD., 

Professor of Physiology in the University of Pennsylvania. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. With an Intro- 
ductory Section on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Section I. Histology. 
Section II. Bones and Joints. Section III. Muscles and Fascle. Section IV. 
Arteries, Veins and Lymphatics. Section V. Nervous System. Section VI. 
Organs of Sense, of Digestion and Genito-Urinary Organs, Embryology, 
Development, Teratology, Superficial Anatomy, Post-Mortem Examinations, 
and General and Clinical Indexes. Price per Section, $3.50 ; also bound in one 
volume, cloth, $23.00 ; very handsome half Kussia, raised bands and open back, $25.00. 
For sale by subscription only. Apply to the Publishers. 



It is to be considered a study of applied anatomy 
iD its widest sense— a systematic presentation of 
such anatomical facts as can be applied to the 
practice of medicine as well as of surgery. Our 
author is concise, accurate and practical in his 
statements, and succeeds admirably in infusing 
an interest into the study of what is generally con- 
sidered a dry subject. The department of Histol- 
ogy is treated in a masterly manner, and the 
ground is travelled over by one thoroughly famil- 
iar with it. The illustrations are made with great 



care, and are simply superb. There is as much 
of practical application of anatomical points to 
the every-day wants of the medical clinician as 
to those of the operating 3urgeon. In fact few 
general practitioners will read the work without a 
feeling of surprised gratification that so many 
pcints, concerning which they may never ha^e 
thought before are so well presented for their con- 
sideration. It is a work which is destined to be 
the best of its kind in any language.— Medical 
Record, Nov. 25, 1882. 



CLARKE, W. B., F.B. C.S. & LOCKWOOI), C. B., F.B. C.S. 

Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. 
The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 
49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 31. 

J^essrs.Clarke and Lockwood have written abook j intimate association with students could have 
thtt can hardly be rivalled as a practical aid to the given. With such a guide as this, accompanied 
dissector. Their purpose, which is "how to de- | by so attractive a commentary as Treves' Surgical 
scribe the best way to display the anatomical I Applied Anatomy (same series), no student could 
structure," has been fully attained. They excel in j fail to be deeply and absorbingly interested in the 
a lucidity of demonstration and graphic terseness i study of anatomy.— New Orleans Medical and Sur- 
of expression, which only a long training and \ gical Journal, April, 1884. 



MIBST, BABTONC., M.D., & JPIEBSOL, GEO. A., M.I). 

Professor of Obstetrics in the University Professor of Anatomy and Embryology in 

of Pennsylvania. the University of Pennsylvania. 

Human Monstrosities. Magnificent folio, containing about 120 pages of text, 
illustrated with engravings, and many photographic plates from nature. In four parts, 
price, each, $5, Limited edition, for sale by subscription only. Address the Publishers. 



TBEVES, FBEDEBICK, F. B. C. S., 

Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. 
Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, 
with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, 
page 31. 

BELLAMY, EDWABD, F. B. C. S., 

Senior Assistant-Surgeon to the Charing- Cross Hospital, London. 

The Student's Guide to Surgical Anatomy : Being a Description of the 
most Important Surgical Kegions of the Human Body, and intended as an Introduction to 
operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. 

WILSON, EBASMUS, F. B. S. 

A System of Human Anatomy, General and Special. Edited by W. H, 
Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of 
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. 
Cloth, $4.00; leather, $5.00. 

CLELANB, JOMN, M. !>., F. B. S., 

Professor of Anatomy and Physiology in Queen's College, Qalway. 

A Directory for the Dissection of the Human Body. 

volume of 178 pages. Cloth, $1.25. 



In one 12mo. 



HARTSHORNE'S HANDBOOK OF ANATOMY 
AND PHYSIOLOGY. Second edition, revised. 
In one royal 12mo. volume of 310 pages, with 220 
woodcuts. Cloth, $1.75. 



HORNER'S SPECIAL ANATOMY AND HISTOL- 
OGY. Eighth edition, extensively revised and 
modified. In two octavo volumes of 1007 pages, 
with 320 woodcuts. Cloth, $6.00. 



Lea Brothers & Co.'s Publications — Physics, Physiol., Anat. 



DRAPER, JOHN C, M. I)., LL. D., 

Professor of Chemistry in the University of the City of New York. 
Medical Physics. A Text-book for Students and Practitioners of Medicine. 
one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. 



In 



FROM THE PREFACE. 



The fact that a knowledge of Physics is indispensable to a thorough understanding of 
Medicine has not been as fully realized in this country as in Europe, where the admirable 
works of Desplats and Gariel, of Robertson and of numerous German writers constitute a 
branch of educational literature to which we can show no parallel. A full appreciation 
of this the author trusts will be sufficient justification for placing in book form the sub- 
stance of his lectures on this department of science, delivered during many years at the 
University of the City of New York. 

Broadly speaking, this work aims to impart a knowledge of the relations existing 
between Physics and Medicine in their latest state of development, and to embody in the 
pursuit of this object whatever experience the author has gained during a long period of 
teaching this special branch of applied science. 

No man in America was better fitted than Dr. 



"While all enlightened physicians will agree that 
a knowledge of physics is desirable for the medi- 
cal student, only those actually engaged in the 
teaching of the primary subjects can be fully 
aware of the difficulties encountered by students 
who attempt the study of these subjects without 
a knowledge of either physics or chemistry. 
These are especially felt by the teacher of physi- 
ology. 

It is, however, impossible for him to impart a 
knowledge of the main facts of his subject and 
establish them by reasons and experimental dem- 
onstration, and at the same time undertake to 
teach ab initio the principles of chemistry or phys- 
ics. Hence the desirability, we may say the 
necessity, for some such work as the present one. 



Draper for the task he undertook, and he has pro- 
vided the student and practitioner of medicine 
with a volume at once readable and thorough. 
Even to the student who has some knowledge of 
physics this book is useful, as it shows him its 
applications to the profession that he has chosen. 
Dr. Draper, as an old teacher, knew well the diffi- 
culties to be encountered in bringing his subject 
within the grasp of the average student, and that 
he has succeeded so well proves once more that 
the man to write for and examine students is the 
one who has taught and is teaching them. The 
book is well printed and fully illustrated, and in 
every way deserves grateful recognition. — The 
Montreal Medical Journal, July, 1890. 



ROBERTSON, J. McGREGOR, M. A., M. B., 

Muirhead Demonstrator of Physiology, University of Glasgow. 
Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra- 
tions. Limp cloth, $2.00. See Students' Series of Manuals, page 31. 

The title of this work sufficiently explains the 
nature of its contents. It is designed as a man- 
ual for the student of medicine, an auxiliary to 
his text-book in physiology, and it would be particu- 
larly useful as a guide to his laboratory experi- 



ments. It will be found of great value to the 
practitioner. It is a carefully prepared book of 
reference, concise and accurate, and as such we 
heartily recommend it. — Journal of the American 
Medical Association, Dec. 6, 1884. 



I) ALTON, JOHN €., M. D*, 

Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York. 

Doctrines of the Circulation of the Blood. A History of Physiological 
Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 
12mo. volume of 293 pages. Cloth, $2. 



Dr. Dalton's work is the fruit of the deep research 
of a cultured mind, and to the busy practitioner it 
cannot fail to be a source of instruction. It will 
inspire him with a feeling of gratitude and admir- 
ation for those plodding workers of olden times, 
who laid the foundation of the magnificent temple 
of medical science as it now stands. — New Orleans 
Medical and Surgical Journal, Aug. 1885. 

In the progress of physiological study no fact 
was of greater moment, none more completely 



revolutionized the theories of teachers, than the 
discovery of the circulation of the blood. This 
explains the extraordinary interest it has to all 
medical historians. The volume before us is one 
of three or four which have been written within a 
few years by American physicians. It is in several 
respects the most complete. The volume, though 
small in size, is one of the most creditable con- 
tributions from an American pen to medical history 
that has appeared. — Med. & Surg. Rep., Dec. 6, 1884. 



BELL, F. JEFFREY, M. A., 

Professor of Comparative Anatomy at King's College, London. 

Comparative Physiology and Anatomy. In one 12mo. volume of 561 pages, 
with 229 illustrations. Limp cloth, $2.00. See Students' Series of Manuals, page 31 . 
The manual is preeminently a student's book- 



clear and simple in language and arrangement 
It is well and abundantly illustrati * 



able and interesting. 



llustrated, and is read- 
On the whole we consider 



it the best work in existence in the English 
language to place in the hands of the medical 

student. — Bristol Medico-Chirurgical Journal, Mar. 



ELLIS, GEORGE VINER, 

Emeritus Professor of Anatomy in University College, London. 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. From the eighth and revised London edition. In one very 
handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25 ; leather. $535. 

ROBERTS, JOHN B., A. 31., M. I>., 

Lecturer in Anatomy in the University of Pennsylvania. 
The Compend of Anatomy. For use in the dissecting-room and in preparing 
for examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. 



8 Lea Brothers & Co/s Publications — Physiology, Chemistry, 



CHAPMAN, HENRY a, M. I)., 

Professor of Institutes of Medicine and Medical Juris, in the Jefferson Med. Coll. of Philadelphia. 

A Treatise on Human Physiology. In one handsome octavo volume of 
925 pages, with 605 fine engravings. Cloth, $5.50; leather, $6.50. 

farther, and the latter will find entertainment and 
instruction in an admirable book of reference.— 
North Carolina Medical Journal, Nov. 18&7. 



It represents very fully the existing state of 
physiology. The present, work has a special value 
to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine. — Buf- 
falo Medical and Surgical Journal, Dec. 1887. 

Matters which have a practical bearing on the 
practice of medicine are lucidly expressed; tech- 
nical matters are given in minute detail; elabo- 
rate directions are stated for the guidance of stu- 
dents in the laboratory. In every respect the 
work fulfils its promise, whether as a complete 
treatise for the student or for the physician ; for 
the former it is so complete that he need look no 



The work certainly commends itself to both 
student and practitioner. What is most demanded 
by the progressive physician of to-day is an adap- 
tation of physiology to practical therapeutics, and 
this work is a decided improvement in this respect 
over other works in the market. It will certainly 
take place among the most valuable text-books. — 
Medical Age, Nov. 25, 1887. 

It is the production of an author delighted with 
his work, and able to inspire students with an en- 
thusiasm akin to his own. — American Practitioner 
and News, Nov. 12, 1887. 



dalton, john a, m. n., 

Professor of Physiology in the College of Physicians and Surgeons, New York, etc. 

A Treatise on Human Physiology. Designed for the use of Students and 
Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one 
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, 
$5.00; leather, $6.00. 



From the first appearance of the book it has 
been a favorite, owing as well to the author's 
renown as an oral teacher as to the charm of 
simplicity with which, as a writer, he always 
succeeds in investing even intricate subjects. 
It must be gratifying to him to observe the fre- 
quency with which his work, written for students 
and practitioners, is quoted by other writers on 
physiology. This fact attests its value, and, in 
great measure, its originality. It now needs no 
such seal of approbation, however, for the thou- 
sands who have studied it in its various editions 



have never been in any doubt as to its sterling 
worth.— N. Y. Medical Journal, Oct. 1882. 

Professor Dal ton's well-known and deservedly- 
appreciated work has long passed the stage at 
which it could be reviewed in the ordinary sense. 
The work is eminently one for the medical prac- 
titioner, since it treats most fully of those branches 
of physiology which have a direct bearing on the 
diagnosis and treatment of disease. The work is 
one which we can highly recommend to all our 
readers. — Dublin Journal of Medical Science, Feb.'83. 



FOSTER, MICHAEL, M. &., F. R. 8., 

Prelector in Physiology and Fellow of Trinity College, Cambridge, England. 
Text-Book of Physiology. New (fourth) and enlarged American from the 
fifth and revised English edition, with notes and additions. In one handsome octavo vol- 
ume of about 900 pages, with about 300 illustrations. Ready in a few days. 

A REVIEW OF THE FIFTH ENGLISH EDITION IS APPENDED. 
It is delightful to meet a book which deserves I tions, and his energies are not frittered away and 
only unqualified praise. Such a book is now before ' degenerated on petty and trivial details. Review- 
us. It is in all respects an ideal text-book. With a 
complete, accurate and detailed knowledge of his 
subject, the author has succeeded in givin 



thoroughly consecutive and philosophic account 
of the science. A student's attention is kept 
throughout fixed on the great and salient ques- 



this volume as a whole we are justified in say- 
ing that it is the only thoroughly good text-book 
of physiology in the English language, and that it 
is probably the best text-book in any language. 
—Edinburgh Medical Journal. 



FOWER, HENRY, M. B. 9 F. R. C. 8., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. Second edition. In one handsome pocket-size 12mo. vol- 
ume of 509 pp., with 68 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 31. 

SIMON, W., Flu n., M. n., 

Professor of Chemistry and. Toxicology in the College of Physicians and Surgeons, Baltimore, and 
Professor of Chemistry in the Maryland College of Pharmacy. 

Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners 
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. 
New (second) edition. In one 8vo. vol. of 478 pp., with 44 woodcuts and 7 colored plates 
illustrating 56 of the most important chemical tests. Cloth, $3.25. 



In this book the author has endeavored to meet 
the wants of the student of medicine or pharmacy 
in regard to his chemical studies, and he has suc- 
ceeded in presenting his subject so clearly that no 
one who really wishes to acquire a fair knowledge 
of chemistry can faif to do so with the help of this 
work. The largest section of the book is naturally 
that devoted to the consideration of the carbon 
compounds, or organic chemistry. An excellent 



feature is the introduction of a number of plates 
showing the various colors of the most important 
chemical reactions of the metallic salts, of some 
of the alkaloids, and of the urinary tests. In the 
part treating of physiological chemistry the section 
on analysis of the urine will be found very practi- 
cal, and well suited to the needs of the practitioner 
of medicine.— The Medical Record, May 25, 1889. 



Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated 
by Ira Eemsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. 



LEHM ANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. In one octavo volume of 327 pages, 
with 41 illustrations. Cloth, $2.25. 

CA.RPENTER'8 HUMAN PHYSIOLOGY. Edited 
by Henbt Powee. In one octavo volume. 



CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse of Alcoholic Liquoes in Health and Dis- 
ease. With explanations of scientific words. Small 
12mo. 178 pages. Cloth, 60 cents. 



Lea Brothers & Co.'s Publications — Chemistry. 



FBANKLANI>,E.,D. C.L.,F.B.S.,&JAPP, F.R.,F.I C, 



Professor of Cliemistry in the Normal School 
of Science, London. 



Assist. Prof, of Chemistry in the Normal 
School of Science, London. 



Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51 
woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 

This excellent treatise will not fail to take its 



This work should supersede other works of its 
class in the medical colleges. Itis certainly better 
adapted than any work upon chemistry.with which 
we are acquainted, to impart that clear and full 
knowledge of the science which students of med- 
icine should have. Physicians who feel that their 
chemical knowledge is behind the times, would 
do well to study this work. The descriptions and 
demonstrations are made so plain that there is 
no difficulty in understanding them.— Cincinnati 
Medical News, January, 1886. 



place as one of the very best on the subject of 
which it treats. We have been much pleased 
with the comprehensive and lucid manner in 
which the difficulties of chemical notation and 
nomenclature have been cleared up by the writers. 
It shows on every page that the problem of 
rendering the obscurities of this science easy 
of comprehension has long and successfully 
engaged the attention of the authors.— Medical 
and Surgical Reporter, October 31, 1885. 



FOWNES, GEOBGE, Ph. D. 

A Manual of Elementary Chemistry; Theoretical and Practical. Em- 
bodying Watts' Physical and Inorganic Chemistry. New Ameri can , from the twel fth English 
edition. In one large royal 12mo. volume of 1061 pages, with 168 illustrations on wood 
and a colored plate. Cloth, $2.75 ; leather, $3.25. 



Fownes 1 Chemistry has been a standard text- 
book upon chemistry for many years. Its merits 
are very fully known by chemists and physicians 
everywhere in this country and in England. As 
the science has advanced by the making of new 
discoveries, the work has been revised so as to 
keep it abreast of the times. It has steadily 
maintained its position as a text-book with medi- 
cal students. In this work are treated fully : Heat, 
Light and Electricity, includin g Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
important kind, and should be familiar to every 
medical practitioner. We can commend the 



work as one of the very best text-books upon 
chemistry extant. — Cincinnati Med. News, Oct. '85. 
Of all the works on chemistry intended for the 
use of medical students, Fownes' Chemistry is 
perhaps the most widely used. Its popularity is 
based upon its excellence. This last edition con- 
tains all of the material found in the previous, 
and it is also enriched by the addition of Watts* 
Physical and Inorganic Chemistry. All of the mat- 
ter is brought to the present standpoint of chemi- 
cal knowledge. We may safely predict for this 
work a continuance of the fame and favor it enjoys 
among medical students. — New Orleans Medical 
and Surgical Journal, March, 1886. 



ATTFIELD, JOHN, M. A., Fh. D., F. I. C. 9 F. B. S., Etc. 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. 

Chemistry, General, Medical and Pharmaceutical; Including the Chem- 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, 
and their Application to Medicine and Pharmacy. A new American, from the twelfth 
English edition, specially revised by the Author for America. In one handsome royal 
12mo. volume of 782 pages, with 88 illustrations. Cloth, $2.75; leather, $3.25. 



Attfield's Chemistry is the most popular book 
among students of medicine and pha; macy. This 
popularity has a good, substantial basis. It rests 
upon real merits. Attfield's work combines in the 
happiest manner a clear exposition of the theory 
of chemistry with the practical application of this 
knowledge to the everyday dealings of the phy- 
sician and pharmacist. His discernment is shown 
not only in what he puts into his work, but also in 
what he leaves out. His book is precisely what 
the title claims for it. The admirable arrangement 
of the text enables a reader to get a good idea of 
chemistry without the aid of experiments, and 



again it is a good laboratory guide, and finally it 
contains such a mass of well-arranged information 
that it will always serve as a handy book of refer- 
ence. He does not allow anyunutilizable knowl- 
edge to slip into his book; his long years of 
experience have produced a work which is both 
scientific and practical, and which shuts out 
everything in the nature of a superfluity, and 
therein lies the secret of its success. This last 
edition shows the marks of the latest progress 
made in chemistry and chemical teaching.— Nc 10 
Orleans Medical and Surgical Journal, Nov. 1S89. 



BLOXAM, CHARLES L., 

Professor of Chemistry in King's College, London. 

Chemistry, Inorganic and Organic. New American from the fifth Lon- 
don edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $2.00 ; leather, $3.00. 



Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the student never has occasion to 
complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations of 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 



maintains the position it has always held as one of 
the best manuals of general chemistry tn the Eng- 
lish language. — Detroit Lancet, Feb. 1884. 

We know of no treatise on chemistry which 
contains so much practical information in the 
same number of pages. The book can be readily 
adapted not only to the needs of those who desire 
a tolerably complete course of chemistry, but also 
to the needs of those who desire only' a genera) 
knowledge of the subject. It is both a satisfactory 
text book, and a useful book of reference.— Boston 
Medical and Surgical Journal, June 19, 1884. 



GREENE, WILLIAM JT., M. D., 

Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. 

A Manual of Medical Chemistry. For the use of Students. Based upon Bow- 
man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 
It is a concise manual of three hundred pages, the recognition of compounds due to pathologi* al 
giving an excellent summary of the best methods conditions. The detection of poisons is treated 
of analyzing the liquids and solids of the body, both with sufficient fulness for the purpose of the sut- 
ler the estimation of their normal constituent and dent or practitioner.— Boston Ji. iue,'>0. 



10 



Lea Brothers & Co.'s Publications — Chemistry. 



REMSEW, IRA, M. D., Fh. D., 

Professor of Chemistry in the Johns Hopkins University, Baltimore* 
Principles Of Theoretical Chemistry, with special reference to the Constitu- 
tion of Chemical Compounds. New (third) and thoroughly revised edition. In one hand- 
some royal 12mo. volume of 316 pages. Cloth, $2.00 



This work of Dr. Remsen is the very text-book 
needed, and the medical student who has it at 
his fingers' ends, so to speak, can, if he chooses, 
make himself familiar with any branch of chem- 
istry which he may desire to pursue. It would be 
difficult indeed to find a more lucid, full, and at 
the same time compact explication of the philos- 
ophy of chemistry, than the book before us, and 
we recommend it to the careful and impartial 



examination of college faculties as the text-book oi 
chemical instruction.— Sit. Louis Medical and Sur- 
gical Journal, January, 1888. 

It is a healthful sign when we see a demand for 
a third editicn of such a book as this. This edi- 
tion is larger than the last by about seventy-five 
pages, and much of it has been rewritten, thus 
bringing it fully abreast of the latest investiga- 
tions.— N. Y. Medical Journal, Dec. 31, 1887. 



CHARLES, T. CRANSTOVJST, M. D., F. C. S., M. S., 

Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast. 

The Elements of Physiological and Pathological Chemistry. A 

Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a»practical course of instruction for students. In one handsome octavo 
volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 



Dr. Charles is fully impressed with the impor- 
tance and practical reach of his subject, and he 
has treated it in a competent and instructive man- 
ner. We cannot recommend a better book than 
the present. In fact, it fills a gap in medical text- 
books, and that is a thing which can rarely be said 



nowadays. Dr. Charles has devoted much space 
to the elucidation of urinary mysteries. He does 
this with much detail, and yet in a practical and 
intelligible manner. In fact, the author has filled 
his book with many practical hints.— Medical Rec- 
ord, December 20, 1884. 



HOFFMANN, F, A.M., Ph.D., & FOWER, F.B., Fh.D., 

Pvhlic Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal 
Chemicals and their Preparations. Being a Guide for the Determination of their Identity 
and Quality, and for the Detection of Impurities and Adulterations. For the use of 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one very 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 



We congratulate the author on the appearance 
of the third edition of this work, published for the 
first time in this country also. It is admirable and 
the information it undertakes to supply is both 
extensive and trustworthy. The selection of pro- 
cesses for determining the purity of the substan- 
ces of which it treats is excellent and the descrip- 



tion of them singularly explicit. Moreover, it is 
exceptionally free from typographical errors. We 
have no hesitation in recommending it to those 
who are engaged either in the manufacture or the 
testing of medicinal chemicals.— London Pharma- 
ceutical Journal and Transactions, 1883. 



CLOWES, FRANK, D. So., London, 

Senior Science- Master at the High School, Newcastle-under-Lyme, etc. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Third American from the fourth and revised English edition. 
In one 12mo. volume of 387 pages, with 55 illustrations. Cloth, $2.50. 



This work has long been a favorite with labora- 
tory instructors on account of its systematic plan, 
carrying the student step by step from the simplest 
questions of chemical analysis, to the more recon- 
dite problems. Features quite as commendable 
are the regularity and system demanded of the 



student in the performance of each analysis. 
These characteristics are preserved in the present 
edition, which we can heartily recommend as a sat- 
isfactory guide for the student of inorganic chem- 
ical analysis. — New York Medical Journal, Oct. 9, 
1886. 



RALFE, CHARLES H., M. D., F. R. C. F., 

Assistant Physician at the London Hospital. 

Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 

See Students' Series of Manuals, page 31. 
cine. Dr. Ralfe is thoroughly acquainted with the 
latest contributions to his science, and it is quite 



illustrations. Limp cloth, red edges, $1.50 
This is one of the most instructive little works 
that we have met with in a long time. The author 
is a physici 
ist, cons 

tical, telling the physician just wnat ne oug 
know, of the applications of chemistry in medi 



sician and physiologist, as well as a chem- 
sequently the book is unqualifiedly prac- 
lling the physician just what he ought to 



refreshing to find the subject dealt with so clearly 
and simply, yet in such evident harmony with the 
modern scientific methods and spirit. — Medical 
Record, February 2, 1884. 



CLASSED, ALEXANDER, 

Professor in the Royal Polytechnic School, Aix-la-Chapelle. 

Elementary Quantitative Analysis. Translated, with notes and additions, by 
Edgab F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 pages, with 36 illus. Cloth, $2.00. 

It is probably the best manual of an elementary and then advancing to the analysis of minerals and 
nature extant, insomuch as its methods are the such products as are met with in applied chemis- 
best. It teaches by examples, commencing with try. It is an indispensable book for student^ in 
single determinations, followed by separations, chemistry. — Boston Journal of Chemistry, Oct. 1878 



Lea Brothers & Co.'s Publications — Pharm., Mat. Med., Therap. 11 



SAME, HOB ART AMORT, B. Sc, M. JD., 

Professor of Materia Medica and Therapeutics in the Jefferson Medical College of Philadelphia; 
Secretary of the Convention for the Revision of the United States Pharmacopce'ai of 1890. 

A Text-Book of Practical Therapeutics; With Especial Keference to the 
Application of Remedial Measures to Disease and their Employment upon a Rational 
Basis. With special chapters by Drs. G. E. de Schweinitz, Edward Martin, 
J. Howard Reeves and Barton C. Hirst. New (2d) and revised edition, in one 
handsome octavo volume of 650 pages. Cloth, $3.75 ; leather, $4.76. Just ready. 
This work has received the rare distinction ' other features of this practically helpful treatise 



among medical works of reaching a second edition 
six months after its first appearance. We note 
among the important new features characterizing 
the second edition, additional information regard- 
ing the remedies recently added to the Materia 
Medica; the method of employing the rest cure; 
the use of suspension in the treatment ol locomo- 
tor ataxia and allied affections. Many new pre- 
scriptions have also been inserted to illustrate 
the best modes of applying remedies. Among 



which will make reference to it convenient and 
profitable, are the arrangement of titles of drugs 
and diseases in alphabetical order, according to 
their English names; the introduction of the 
preparations of the British Pharmacopoeia; a dose 
list of drugs officinal and nnofficinal. In addition 
to the general index, a copious and explanatory 
index of diseases an ' remedies has been appended 
which will render the contents easily accessible. 
— The Medical Age, July 10, 1891. 



HARE, HOB ART AMORT, B. Sc, M. JD., Editor. 

A System of Practical Therapeutics ; By American and Foreign Authors. 
In a series of contributions by seventy-seven eminent physicians.- In three large octavo 
volumes of about 1000 pages each, with illustrations. For sale by subscription only. 
In press. 

BRUNTON, T. LAUDER, M.I)., D.Sc, F.R.S., E.R.C.P., 

Lecturer on Materia Medica and Therapeutics at St. Bartholomew's Hospital, London, etc. 

A Text-Book of Pharmacology, Therapeutics and Materia Medica; 

Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. 
Third edition. Octavo, 1305 pages, 230 illustrations. Cloth, $5.50; leather, $6.50. 



No words of praise are needed for this work, for 
it has already spoken for itself in former editions. 
It was by unanimous consent placed among the 
foremost books on the subject ever published in 
any language, and the better it is known and studied 
the more highly it is appreciated. The present 
edition contains much new matter, the insertion 
of which has been necessitated by the advances 



made in various directions in the art of therapeu- 
tics, and it now stands unrivalled in its thoroughly 
scientific presentation of the modes of drug action. 
No one who wishes to be fully up to the times in 
this science can afford to neglect the study of Dr. 
Brunton's work. The indexes are excellent, and 
add not a little to the practical value of the book. 
—Medical Record, May 25, 1889. 



MAISCH, JOHNM., Pilar. &., 

Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 

A Manual of Organic Materia Medica; Being a Guide to Materia Medica of 
the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists 
and Physicians. New (4th) edition, thoroughly revised. In one handsome royal 12mo. 
volume of 529 pages, with 258 illustrations. Cloth, $3.00. 



For everyone interested in materia medica, 
Maisch's Manual, first published in 1882, and now 
in its fourth edition, is an indispensable book. 
For the American pharmaceutical student it is 
the work which will give him the necessary knowl- 
edge in the easiest way, partly because the text is 
brief, concise, and free from unnecessary matter, 
and partly because of the numerous illustrations, 
which bring facts worth knowing immediately be- 



fore his eyes. That it answers its purposes in this 
respect the rapid succession of editions is the best 
evidence. It is the favorite book of the American 
student even outside of Maisch's several hundred 
personal students. The arrangement of its con- 
tents shows the practical tendency of the book. 
Maisch's system of classification is easy and com- 
prehensive. — Pharmaceutische Zeitung, Germanv, 
1890. 



JPARRI8H, EJDWARI?, 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. 
> A Treatise on Pharmacy : Designed as a Text-book for the Student, and as a 
Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
Fifth edition, thoroughly revised, by Thomas S. Wiegand, Ph. G. In one handsome 
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5.00 ; leather, $6.00. 

No thorough-going pharmacist will fail to possess ods of combination are concerned, can afford to 
himself of so useful a guide to practice, and no leave this work out of the list of their works of 
physician who properly estimates the value of an reference. The country practitioner, who must 
accurate knowledge of the remedial agents em- always be in a measure his own pharmacist, will 
ployed by him in daily practice, so far as their find it indispensable.— Louisville Medica! News. 
miscibihty, compatibility and mosteffective meth- March 29, 1884. 



HERMANN, Dr. L., 

Professor of Physiology in the University of Zurich. 
Experimental Pharmacology. A Handbook of Methods for Determining the 
Physiological Actions of Drugs. Translated, with the Author's permission, and with 
extensive additions, by Kobert Meade Smith, M. D., Demonstrator of Physiology in the 
University of Pennsylvania. 12mo., 199 pages, with 32 illustrations Clot h, "$1.50. 

STILLE, ALFRED, M. J)., LL. IX, 

Professor of Theory and Practice of Mai. and of Clinical Med. in the Univ. ofPmna. 

Therapeutics and Materia Medica. A Systematic Treatise on the Action and 
Uses of Medicinal Agents, including their Description and History. Fourth edition. 
revised and enlarged. In two large and handsome octavo volumes, containing 1936 pases, 
Cloth, $10.00; leather, $12.00. 



12 Lea Brothers & Co.'s Publications — Mat. Med., Therap. 



STILLE, A., 31. L>., LL. D., & MAISCH, J. M., Phar. D., 



Professor Emeritus of the Theory and Prac- 
tice of Medicine and of Clinical Medicine 
in the University of Pennsylvania. 



Prof, of Mat. Med. and Botany in Phila. 
College of Pharmacy, Sec' y to the Ameri 
can Pharmaceutical Association. 



The National Dispensatory. 

CONTAINING THE NATURAL HISTORY, CHEMISTRY, PHARMACY, ACTIONS AND USES OF 

MEDICINES, INCLUDING THOSE RECOGNIZED IN THE PHARMACOPEIAS OF THE 

UNITED STATES, GREAT BRITAIN AND GERMANY, WITH NUMEROUS 

REFERENCES TO THE FRENCH CODEX. 

Fourth edition revised, and covering the new British Pharmacopoeia. In one mag- 
nificent imperial octavo volume of 1794 pages, with 311 elaborate engravings. Price 
in cloth, $7.25 ; leather, raised bands, $8.00. \*Thi8 work will be furnished with Patent 
Beady Reference Thumb-letter Index for $1.00 in addition to the price in any style of binding. 



It is with much pleasure that the fourth edition 
of this magnificent work is received. The authors 
and publishers have reason to feel proud of this, 
the most comprehensive, elaborate and accurate 
work of the kind ever printed in this country. It 
is no wonder that it has become the standard au- 
thority for both the medical and pharmaceutical 
profession, and that four editions have been re- 
quired to supply the constant and increasing 
demand since its first appearance in 1879. The 
■entire field has been gone over and the various 
articles revised in accordance with the latest 
developments regarding the attributes and thera- 
peutical action of drugs. The remedies of recent 



discovery have received due attention.— Kansas 
City Meoical Index, Nov. 1887. 

We think it a matter for congratulation that the 
profession of medicine and that of pharmacy have 
shown such appreciation of this great work as to call 
for four editions within the comparatively brief 
period of eight years. The matters with which it 
deals are of Sv practical a nature that neither the 
physician nor the pharmacist can do without the 
latest text-books on them, especially those that are 
so accurate and comprehensive as this one. The 
book is in every way creditable both to the authors 
and to the publishers. — New York Medical Journal, 
May 21, 1887. 



COHEN, SOLOMON SOLIS, M. L>., 

Pi ofessor of Clinical Medicine and Applied Therapeutics in the Philadelphia Polyclinic. 
A Handbook of Applied Therapeutics. Being a Study of Principles, 
Applicable and an Exposition of Methods Employed in the Management of the Sick. 
In one large 12mo. volume, with illustrations. Preparing. 

FABQUHABSON, BOBEBT, M. JD., F. B. C. P., LL. D. 9 

Lecturer on Materia Medica at St. Mary's Hospital Medical School, London. 

A Guide to Therapeutics and Materia Medica. New (fourth) American, 
trom the fourth English edition. Enlarged and adapted to the IT. S. Pharmacopoeia. By 
Frank Woodbury, M. D., Professor of Materia Medica and Therapeutics and Clinical 
Medicine in the Medico- Chirurgical College of Philadelphia. In one handsome 12mo. 
volume of 581 pages. Cloth, $2.50. 



It may correctly be regarded as the most modern 
work of its kind. It is concise, yet complete. 
Containing an account of all remedies that have 
a place in the British and United States Pharma 
copceias, as well as considering all non-official but 
important new drugs, it becomes in fact a miniature 
dispensatory. — Pacific Medical Journal, June, 1889. 

An especially attractive feature is an arrange 
ment by which the physiological and therapeutical 



actions of various remedies are shown in parallel 
columns. This aids gpeatly in fixing attention and 
facilitates study. The American editor has en- 
larged the work so as to make it include all the 
remedies and preparations in the U. S. Pharma- 
copoeia The book is a most valuable addition to 
the list of treatises on this most important subject. 
— American Practitioner and News, Nov. 9, 1889. 



EDES, BOBEBT T., 31. Z>., 

Jackson Professor of Clinical Medicine in Harvard University, Medical Department. 

A Text-Book of Therapeutics and Materia Medica. Intended for the 
Use of Students and Practitioners. Octavo, 544 pages. Cloth, $3.50 ; leather, $4.50. 



The present work seems destined to take a promi- 
nent place as a text-book on the subjects of which 
it treats. It possesses all the essentials which we 
expect in a book of its kind, such as conciseness, 
clearness, a judicious classification, and a reason- 
able degree of dogmatism. All the newest drugs 
of promise are treated of. The clinical index at 
the end will be found very useful. We heartily 



commend the book and congratulate the author 
on having produced so good a one. — N. Y. Medical 
Journal, Feb. 18, 1888. 

Dr. Edes' book represents better than any older 
book the practical therapeutics of the present 
day. The book is a thoroughly practical one. The 
classification of remedies has reference to their 
therapeutic action.— Pharmaceutical Era, Jan. 1888. 



BBTJCE, J. MITCHELL, 31. L>., F. B. C. P., 

Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London. 
Materia Medica and Therapeutics. An Introduction to Rational Treatment. 
Fourth edition. 12mo., 591 pages. Cloth, $1.50. See Student^ Series of Manuals, page 31. 



GBIFFITH, BOBEBT EGLESFIELD, 31. D. 

A Universal Formulary, containing the Methods of Preparing and Adminis- 
tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- 
ists. Third edition, thoroughly revised, with numerous additions, by John M. Maisch, 
P liar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 
In one octavo volume of 775 pages, with 38 illustrations. Cloth, $4.50 ; leather, $5.50. 



Lea Brothers & Co.'s Publications — Pathol., HistoL 



13 



GIBBES, HEJSTEAGE, 31. D., 

Professor of Pathology in the University of Michigan, Medical Department. 

Practical Pathology and Morbid Histology. In one very handsome octavo 
volume of 314 pages, with 60 illustrations, mostly photographic. Cloth, $2.75. Just ready. 



Dr. Gibbes' established reputation as a master 
of the technique of microscopy would lead us to 
anticipate a work of great value, and in this we 
are not disappointed. The chapters devoted to 
this subject are models of completeness, con- 
densed m such a manner as to render them of 



the greatest^ possible value to the laboratory 
worker. The author's methods of hardening, 
section-cutting and staining are given in detail, 
and are accompanied by valuable formulae for 
reagents, eta.— The Medical News, July 4, 1891. 



SENN, NICHOLAS, M.JD., Ph.D., 

Professor of Surgery in Rush Medical College, Chicago. 
Surgical Bacteriology. New (second) edition. In one handsome octavo of 
268 pages, with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2. Just ready. 

ner all the literature of a subject, thus saving 
much time. We cordially commend this book 



A very thorough and exhaustive review of cur- 
rent literature of that part of bacteriology relating 
to surgery. Such books as this are of incalcula- 
ble benefit to the general practitioner, as they 
bring before him in a condensed and orderly man- 



ail physicians desirous of keeping pace with mod 
ern investigations. — Cincinnati Lnncet- Clinic, May 
30, 1891. 



GBEEN, T. HENBT, M. H., 

Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. 
Pathology and Morbid Anatomy. New (sixth) American from the seventh 
revised English edition. Octavo, 539 pp., with 167 engravings. Cloth, $2.75. 



The Pathology and Morbid Anatomy of Dr. 
Green is too well known by members of the medi- 
cal profession to need any commendation. There 
is scarcely an intelligent physician anywhere who 
has not the work in his library, for it is almost an 
essential. In fact it is better adapted to the wants 
of general practitioners than any work of the kind 
with which we are acquainted. The works of 
German authors upon pathology, which have been 



translated into English, are too abstruse for the 
physician. Dr. Green's work precisely meets his 
wishes. The cuts exhibit the appearances of 
pathological structures just as they are seen 
through the microscope. The fact that it is so 
generally employed as a text-book by medical stu- 
dents is evidence that we have not spoken too 
much in its favor. — Cincinnati Medical News, Oct. 
1889. 



PAYNE, JOSEPH F., M. !>., F. M. C. P., 

Senior Assistant Physician and Lecturer on Pathological Anatomy, St. Thomas^ Hospital, London, 
A Manual of General Pathology. Designed as an Introduction to the Prac- 
tice of Medicine. Octavo of 524 pages, with 152 illus. and a colored plate. Cloth, $3.50. 

cal factors in those diseases now with reasonable 



Knowing, as a teacher and examiner, the exact 
needs of medical students, the author has in the 
work before us prepared for their especial use 
what we do not hesitate to say is the best introduc- 
tion to general pathology that we have yet ex- 
amined. A departure which our author has 
taken is the greater attention paid to the causa- 
tion of disease, and more especially to the etiologi- 



certainty ascribed to pathogenetic microbes. In 
this department he has been very full and explicit, 
not only in a descriptive manner, but in the tech- 
nique of investigation. The Appendix, giving 
methods of research, is alone worth trie price of the 
book, several times over, to every student of 
pathology. — St. Louis Med. and Surg. Jour., Jan. '89. 



COATS, JOSEPH, M. D., F. F. P. S., 

Pathologist to the Glasgow Western Infirmary. 
A Treatise on Pathology. In one very handsome octavo volume of 829 pages, 
with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. 



Medical students as well as physicians, who 
desire a work for study or reference, that treats 
the subjects in the various departments in a very 
thorough manner, but without prolixity, will cer- 
tainly give this one the preference to any with 
which we are acquainted. It sets forth the most 
recent discoveries, exhibits, in an interesting 



manner, the changes from a normal condition 
effected in structures by disease, and points out 
the characteristics of various morbid agencies, 
so that they can be easily recognized. But, not 
limited to morbid anatomy, it explains fully how 
the functions of organs are disturbed by abnormal 
conditions.— Cincinnati Medical News, Oct. 1883. 



SCHAFEB, EDWABJD A., F. B. S., 

Jodrell Professor of Physiology in University College, London. 

The Essentials of Histology. In oue octavo volume of 246 pases, with 
281 illustrations. Cloth, $2.25. 



KLEIN, E., M. I)., F. B. 8., 

Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew's Hosv., 1 
Elements of Histology. Fourth edition. In one 12mo: volume of 376 paces, 
with 191 illus. Limp cloth, $1.75. See Students'' Series of Manuals, page 31. 



WOODHEAD'S PRACTICAL PATHOLOGY. A 
Mauual for Students and Practitioners. In one 
beautiful octavo volume of 4!>7 pages, with 136 
exquisitely colored illustrations. Cloth, $6 00. 



PEPPER'S SURGICAL PATHOLOGY, Tu oue 
pooket-siae L2mo. volume of 611 yvvces, with si 
illustrations. Limp cloth, rod edges, $2.00. See 
Students Series of Manuals, page 31, 



14 



Lea Brothers & Co.'s Publications— Practice of Med, 



FLINT, AUSTIN, M. D., LL. D., 

Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. Y. 

A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. New (sixth) edition, thoroughly re- 
vised and rewritten by the Author, assisted by William H. Welch, M. D., Professor of 
Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., 
Professor of Physiology, Bellevue Hospital Medical College, N. Y. In one very handsome 
octavo volume of 1160 pages, with illustrations. Cloth, $5.50 ; leather, $6.50. 

in city, town, village, or at some cross-roads, is 
Flint's Practice. "We make this statement to * 
considerable extent from personal observation, and 
it is the testimony also of others. An examina- 
tion shows that very considerable changes have 
been made in the sixth edition. The work may un- 
doubtedly be regarded as fairly representing the 
present state of the science of medicine, and as 
reflecting the views of those who exemplify in 
their practice the present stage of progress of med- 
ical art. — Cincinnati Medical News, Oct. 1886. 



No text-book on the principles and practice of 
medicine has ever met in this country with such 
general approval by medical students and practi- 
tioners as the work of Professor Flint. In all the 
medical colleges of the United States it is the fa- 
vorite work upon Practice; and, as we have stated 
before in alluding to it, there is no other medical 
work that can be so generally found in the libra- 
ries of physicians. In every state and territory 
of this vast country the book that will be most likely 
to be found in the office of a medical man, whether 



BRISTOWE, JOHN SYER, M. D., LL. !>., F. R. S., 

Senior Physician to and Lecturer on Medicine at St. Thomas'' Hospital, London. 

A Treatise on the Science and Practice of Medicine. Seventh edi- 
tion. In one large octavo volume of 1325 pages. Cloth, $6.50 ; leather, $7.50. Just ready. 



The remarkable regularity with which new edi- 
tions of this text-book make their appearance is 
striking testimony to its excellence and value. 
This, too, in spite of the numerous rivals for the 
favor of the student which have been put forth 
within the sixteen years since Bristowe's " Medi- 
cine" first appeared. Nor can it be said that the 
author himself has failed to keep his manual 
abreast of advancing knowledge, arduous as that 
task must prove. So long as there is shown such 
care and circumspection in the inclusion of all 
new matter that has stood the test of criticism, so 
long will this work retain the favor which it has 
always met. For it is a work that is built on a 
stable foundation, systematic, scientific and prac- 
tical, containing the matured experience of a 



physician who has every claim to be considered 
an authority, and composed in a style which at- 
tracts the practitioner as much as the student. No 
one can say that this book has obtained a success 
which was undeserved, and we trust that its author 
will long continue to supervise the production of 
fresh editions for the advantage of the coming 
generation of medical students.— The Lancet, July 
12, 1890. 

Dr. Bristowe's now famous treatise appears in 
its seventh edition. It has long passed the stage 
in which it requires critical examination or com- 
mendation, and has thoroughly established itself 
as among the most complete and useful of text- 
books. — British Medical Journal, September 27, 1890. 



HARTSHORNE, HENRY, M. D., LL. &., 

Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 
royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75 ; half bound, $3.00. 

this one; and probably not one writer in our day 



"Within the compass of 600 pages it treats of the 
history of medicine, general pathology, general 
symptomatology, and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
of its kind that we have seen. — Glasgow Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 
a better average of actual practical treatment than 



had a better opportunity than Dr. Hartshorne for 
condensing all the views of eminent practitioners 
into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen- 
tials, as the name suggests, are not intended to 
supersede the text-books of Flint and Bartholow, 
but they are the most valuable in affording the 
means to see at a glance the whole literature of any 
disease, and the most valuable treatment.— Chicago 
Medical Journal and Examiner, April, 1882. 



REYNOLDS, J. RUSSELL, M. D., 

Professor of the Principles and Practice of Medicine in University College, London. 
A System of Medicine. With notes and additions by Henr? Hartshorne, 
A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large 
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- 
tions. Price per volume, cloth, $5.00 ; sheep, $6.00 ; very handsome half Russia, raised bands, 
$6.50. Per set, clotb, $15.00 ; leather, $18.00. Sold only by subscription. 



STILLE, ALFRED, M. D., LL. D., 

Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 
Cholera : Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- 
ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. 

WATSON, SIR THOMAS, M. !>., 

Late Physician in Ordinary to the Queen. 

Lectures on the Principles and Practice of Physic. A new American 
from the fifth English edition. Edited, with additions, and 190 illustrations, by Henry 
Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. 
In two large octavo volumes of 1840 pages. Cloth, $9.00 ; leather, $11.00. 



Lea Brothers & Co.'s Publications — System of Med. 



15 



For Sale by Subscription Only, 



A System of Pracficai Medicine. 

BY AMERICAN AUTHORS. 
Edited by WILLIAM PEPPER, M. D., LL. D., 

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF 
CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, 

Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the 
Hospital of the University of Pennsylvania. 

The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready. 
Price per volume, cloth, $5; leather, $6 ; half Russia, raised bands and open back, $7. 



In this great work American medicine is for the first time reflected by its worthiest 
teachers, and presented in the full development of the practical utility which is its pre- 
eminent characteristic. The most able men — from the East and the West, from the 
North and the South, from all the prominent centres of education, and from all the 
hospitals which afford special opportunities for study and practice — have united in 
generous rivalry to bring together this vast aggregate of specialized experience. 

The distinguished editor has so apportioned the work that to each author has been 
assigned the subject which he is peculiarly fitted to discuss, and in which his views 
will be accepted as the latest expression of scientific and practical knowledge. The 
practitioner will therefore find these volumes a complete, authoritative and unfailing work 
of reference, to which he may at all times turn with full certainty of finding what he needs 
in its most recent aspect, whether he seeks information on the general principles of medi- 
cine, or minute guidance in the treatment of special disease. So wide is the scope of the 
work that, with the exception of midwifery and matters strictly surgical, it embraces the 
whole domain of medicine, including the departments for which the physician is accustomed 
to rely on special treatises, such as diseases of women and children, of the genito-urinary 
organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology 
and otology. Moreover, authors have inserted the formulas which they have found most 
efficient in the treatment of the various affections. It may thus be truly regarded as a 
Complete Library of Practical Medicine, and the general practitioner possessing it 
may feel secure that he will require little else in the daily round of professional duties. 

In spite of every effort to condense the vast amount of practical information fur- 
nished, it has been impossible to present it in less than 5 large octavo volumes, containing 
about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary 
octavos. Illustrations are introduced wherever requisite to elucidate the text. 

A detailed prospectus will be sent to any address on application to the publishers. 

physicians who are acquainted with all the varie- 
ties of climate in the United States, the character 
of the soil, the manners and customs of the peo- 
ple, etc., it is peculiarly adapted to the wants 
of American practitioners of medicine, and it 
seems to us that every one of them would desire 
to have it. It has been truly called a "Complete 
Library of Practical Medicine," and the general 
practitioner will require little else in his round 
of professional duties. — Cincinnati Medical News, 
March, 1886. 

Each of the volumes is provided with a most 
copious index, and the work altogether promises 
to be one which will add much to the medical 



These two volumes bring this admirable work 
to a close, and fully sustain the high standard 
reached by the earlier volumes; we have only 
therefore to echo the eulogium pronounced upon 
them. We would warmly congratulate the editor 
and his collaborators at the conclusion of their 
laborious task on the admirable manner in which, 
from first to last, they have performed their several 
duties. They have succeeded in producing a 
work which will long remain a standard work of 
reference, to which practitioners will look for 
guidance, and authors will resort for facts. 
From a literary point of view, the work is without 
any serious blemish, and in respect of production, 
it has the beautiful finish that Americans always 
give their works.— Edinburgh Medical Journal, Jan. 
1887. 

* * The greatest distinctively American work on 
the practice of medicine, and, indeed, the super- 
lative adjective would not be inappropriate were 
even all other productions placed in comparison. 
An examination of the five volumes is sufficient 
to convince one of the magnitude of the enter- 
prise, and of the success which has attended its 
fulfilment.— The Medical Age, .July 20, 1886. 

This huge volume form's a fitting close to the 

freat system of medicine which in so short a time 
as won so high a place in medical literature, and 
has done such credit to the profession in this 
country. Among the twenty-three contributors 
are the names of the leading neurologists in 
America, and most of the work in the volume is of 
the higlwH order.— Boston Medical and Surgical 
Journal, July 21, 1S87. 

We consider it one of the grandest works on 
Practical Medicine in the English language. It is 
a work of which the profession of this country can 
feel proud. Writteu exclusively by American 



literature of the present century, and reflect great 
credit upon the scholarship and practical acumen 
of its authors. — The London Lancet, Oct. 3, 1885. 

The feeling of proud satisfaction with which the 
American profession sees this, its representative 
system of practical medicine issued to the medi- 
cal world, is fully justified by the character oi the 
work. The entire caste of the system is in keep- 
ing with the best thoughts of the leaders and fol- 
lowers of our home school of medicine, and the 
combination of the scientific study of disease and 
the practical application of exact and experimen- 
tal knowledge to the treatment of human mal- 
adies, makes every one of us share in the pride 
that has welcomed Dr. Pepper's labors. Sheared 
of the prolixity that wearies the readers of the 
German school, the articles glean these same 
fields for all that is valuable. It is the outcome 
of American brains, aud is marked throughout 
by much of the sturdy independence of thought 
aud originality that is a national characteristic. 
Yet nowhere "is there lack of study of the most 
advanced views of the day.— North Uurotinu Medi- 
cal Journal, Sept. 1886. 



16 



Lea Brothers & Co.'s Publications— Clinical Med., etc. 



FOTHERGILL, J. 31., M. JD., Edin., M. R. C. F., Lond., 

Physician to the City of London Hospital fo^ Diseases of the Chest. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peutics. New (third) edition. In one 8vo. vol. of 661 pages. Cloth, $3.75 ; leather, $4.75. 
To have a description of the normal physiologi- I This is a wonderful book. If there be such a 
cal processes of an organ and of the methods of | thing as "medicine made easy," this is the work to 
treatment of its morbid conditions brought accomplish this result.— Va. Med. Month., June,'87. 
together in a single chapter, and the relations! It is an excellent, practical work on therapeutics, 
between the two clearly stated, cannot fail to prove well arranged and clearly expressed, useful to the 
a great convenience to many thoughtful but busy | student and young practitioner, perhaps even to 



physicians. The practical value of the volume is 
greatly increased by the introduction of many 
prescriptions. That the profession appreciates 
that the author has undertaken an important work 
and has accomplished it is shown by the demand 
for this third edition— xV. Y. Med. Jour., June 11/87. 



the old. — Dublin Journal of Medical Science, March, 
1888. 

We do not know a more readable, practical and 
useful work on the treatment of disease than the 
one we have now before us.— Pacific Medical and 
Surgical Journal, October, 1887. 



VATJGJHAN, VICTOR C, Fh. JD., M.JD., 

Prof, of Phys. and Path. Chem. and Assoc. Prof, of Therap. and Mat. Med. in the Univ. of Mich. 

and JTOVY, FREDERICK G., M. JD. 

Instructor in Hygiene and Phys. Chem. in the Univ. of Mich. 

Ptomaines and Leueomaines, or Putrefactive and Physiological 
Alkaloids. New edition. In one handsome 12mo. volume of 400 pages. Cloth, $2,25. 

Ready shortly. ■ 

FIJSTLAYSON, JAMES, M. JD., Editor, 

, Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 

J Clinical Manual for the Study of Medical Cases. With Chapters 
by Prof. Gairdner on the Physiognomy of Disease; Prof. Stephenson on Diseases of 
the Female Organs ; Dr. Robertson on Insanity ; Dr. Gemmell on Physical Diagnosis ; 
Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor on Case- 
taking, Family History and Symptoms of Disorder in the Various Systems. New edition. 
In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. 

treatise on medical diagnosis, in which every sign 
and s)'mptom of disease is carefully analyzed, and 
their relative significance in the different affec- 
tions in which they occur pointed out. From their 
synthesis the student can accurately determine 
the disease with which he has to deal. The book 
has no competitor, nor is it likely to have as long 
as future editions maintain its present standard of 
excellence. The general practitioner will find 
many practical hints in its pages, while a careful 
study of the work will save him from many pitfalls 
in diagnosis.— Li verpool Medico- Chirurgical Jour- 
nal, January, 1887. 



The profession cannot but welcome the second 
edition of this very valuable work of Finlayson 
and his collaborators. The size of the book has 
been increased and the number of illustrations 
nearly doubled. The manner in which the subject 
is treated is a most practical one. Symptoms 
alone and their diagnostic indications form the 
basis of discussion. The text explains clearly and 
fully the methods of examinations and the con- 
clusions to be drawn from the physical signs.— 
The Medical News, April 23, 1887. 

We are pleased to see a second edition of this 
admirable book. It is essentially a practical 



BROAJDJBENT, W. FT., M. JD., F. R. C. F., 

Physician to and Lecturer on Medicine at St. Mary's Hospital, London. 
The Pulse. In one 12mo. volume of 312 pages. Cloth, $1.75. 
ical Manuals, page 31. 

This little book probably represents the best 
practical thought on this subject in the English 
language. A correct interpretation of the pulse, 
with its almost infinite modifications, brought 
about by almost unlimited bodily variations, can 



See Series of Clin- 



only be achieved by experience, and, as an aid 
toward attaining this goal, nothing will be of more 
service than this brochure on the study of the 
pulse. — The American Journal of Medical Sciences, 
September, 1890. 



HABERSMOW, S. O., M. JD., 

Senior Physician to and late Led. on Principles and Practice of Med. at Guy's Hospital, London. 
On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines and Peritoneum. Second 
American from third enlarged and revised English edition. In one handsome octavo 
volume of 554 pages, with illustrations. Cloth, $3.50. 



This valuable treatise on diseases of the stomach 
and abdomen will be found a cj'clopsedia of infor- 
mation, systematically arranged, on all diseases of 
the alimentary tract, from the mouth to the 
rectum. A fair proportion of each chapter is 
devoted to symptoms, pathology, and therapeutics. 
The present edition is fuller than former ones in 
many particulars, and has been thoroughly revised 
and amended by the author. Several new chap- 
ters have been added, bringing the work fully up 



to the times, and making it a volume of interest to 
the practitioner in every field of medicine and 
surgery. Perverted nutrition is in some form 
associated with all diseases we have to combat, 
and we need all the light that can be obtained on 
a subject so bread and general. Dr. Habershon's 
work is one that every practitioner should read 
and study for himself.— iV. Y. Medical Journal, 
April, 1879. 



TANJnER, THOMAS JELAWKES, M. JD. 

A Manual of Clinical Medicine and Physical Diagnosis. Third American 
from the second London edition. Kevised and enlarged by Tilbury Fox, M. D. 
In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. 

LECTURES ON THE STUDY OF FEVER. By I LA ROCHE ON YELLOW FEVER, considered in 
A. Hudson, M. D., M. R. I. A. In one octavo I ^ nistn^iVal Patholos-iVal Etiological and 
volume of 308 pages. Cloth, $2.50. "* Mlst O;. lc » 1 . ^atnoiogicai, luioiogicai ana 

A TREATISE ON FEVER. By Robert D. Lyons, \ Therapeutical Relations. In two large and hand- 
K. C. C In one 8vo. vol. of 354 pp. Cloth, $2.25. | some octavo volumes of 1468 pp. Cloth, $7.00. 



JiEA Brothers & Co.'s Publications— Hygiene, Electr., Pract. 1? 



BARTHOLOW, ROBERTS, A. M., M. JO., LL. L>., 

Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. 
Medical Electricity. A Practical Treatise on the Applications of Electricity 
to Medicine and Surgery. New (third) edition. In one very handsome octavo volume of 
308 pages, with 110 illustrations. Cloth, $2.50 
The fact that this work has reached its third edi 



tion in six years, and that it has been kept fully 
abreast with the increasing use and knowledge of 
electricity,demonstrates its claim to be considered 
a practical treatise of tried value to the profession. 
The matter added to the present edition embraces 



the most recent advances in electrical treatment. 
The illustrations are abundant and clear, and the 
work constitutes a full, clear and concise manual 
well adapted to the needs of both student and 
practitioner.— The Medical News, May 14, 1887. 



YJEO, I. BJJRNEY, M. D., F. R. C. P., 

Professor of Clinical Therapeutics in King's College, London, and Physician to King's College 
Hospital. 

Pood in Health and Disease. In one 12mo. volume of 590 pages. Cloth, $2. 
See Series of Clinical Manuals, page 31. 

Dr.Yeo supplies in a compact form nearly all that 
the practitioner requires to know on the subject of 
diet. The work is divided into two parts— food in 
health and food in disease. Dr. Yeo has gathered 
together from all quarters an immense amount of 
useful information within a comparatively small 



compass, and he has arranged and digested his 
materials with skill for the use of the practitioner. 
We have seldom seen a book which more thor- 
oughly realizes the object for which it was written 
than this little work of Dr. Yeo.— British Medical 
Journal, Feb. 8, 1890. 



RICHARDSON B. W., M.J}., LL. L>., F.R.S., 

Fellow of the Royal College of Physicians, London. 
Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather $5. 



Dr. Richardson has succeeded in producing a 
work which is elevated in conception, comprehen- 
sive in scope, scientific in character, systematic in 
arrangement, and which is written in a clear, con- 
cise and pleasant manner. He evinces the happy 
faculty of extracting the pith of what is known on 
the subject, and of presenting it in a most simple, 
intelligent and practical form. There is perhaps 
no similar work written for the general public 
thatcontains such acomplete, reliable and instruc- 



tive collection of data upon the diseases common 
to the race, their origins, causes, and the measures 
for their prevention. The descriptions of diseases 
are clear, chaste and scholarly ; the discussion of 
the question of disease is comprehensive, masterly 
and fully abreast with the latest and best knowl- 
edge on the subject, and the preventive measures 
advised are accurate, explicit and reliable. — The 
American Journal of the Medical Sciences, April, 1884. 



THE YEAR-BOOK OF TREATMENT FOR 1891. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine. In one 12mo. volume of 485 pages. Cloth, $1.50. Just ready. 
#\ For special commutations with periodicals see pages 1 and 2. 



The present- issue, the seventh, has been in- 
creased by more than one hundred and fifty pages, 
but the original plan of the book is not altered. 
It still remains a concise epitome of the chief 
articles of the past year— articles selected and 
epitomised by a staff of contributors which in- 
cludes many of the best-known and ablest spe- 
cialists, and these gentlemen have wisely kept in 
mind that the Year Book is for practitioners, and 
they have given what actual practice requires— 
useful, workable information. We have no hesi- 



tancy in recommending the present volume, which 
we consider to be superior to any of its predeces- 
sors; more practical, more generally useful to 
practitioners. The sectional editors have confined 
their attention to fulfilling the object of the book's 
existence— the providing of an epitome of the 
most practical and useful of the medical articles, 
of the past year, for the use of men whose prac- 
tice does not allow time for the study of a large 
number of home and foreign medical journals. — 
The Dublin Journal of Medical Science, May, 1S91.» 



THE YEAR-BOOKS of TREATMENT for '86, '87 and '90 

Similar to above. 12mo., 320-341 pages. Limp cloth, $1.25 each. 

SCHRE1BER, JOSEPH, M. D. 

A Manual of Treatment by Massage and Methodical Muscle Ex- 
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome 
octavo volume of 274 pages, with 117 fine engravings. Cloth, $2.75. 



STURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
l2mo. volume of 127 pages. Cloth, $1.25. 

DAVIS' CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Davis, 
M. D. Edited by Frank H. Davis, M. D. Second 
edition. 12mo. 287 pages. Cloth, $1.75. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
320 pages. Cloth, $2.50. 

PAVY'3 TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth, $2.00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With additions by D. F. Conkie, 
M. D. 1 vol. 8vo., pp. G03. Cloth, $2.50. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand 
some octavo volume of 302 pp. Cloth, $2.75 



HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 

FULLER ON DISEASES OF THE LUNGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition, in one 
octavo volume of 475 pages. Cloth, $3.50. 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. 

SLADEON DIPHTHERIA; its Nature and Treat- 
ment, with au account of the History of its Pre- 
valence in various Countries. Second and revised 
edition. In one 12mo. vol., 15$ pp. Cloth. 11.25, 

SMITH ON CONSUMPTION; its Early and Reme- 
diable Stages. 1 vol. Svo., 253 pp. Cloth, • 

LA ROCHE ON PNEUMONIA. 1 vol. Svo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand oases to exern 
duration. In one Svo. vol. of 303 pp. Clol 



18 Lea Brothers & Co.'s Publications — Throat, L.ungs, Heart, Xerves. 
FLINT, AUSTIN, M. D., LI. D., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. 7. 

A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of 
Diseases of the Lungs and Heart, and of Thoracic Aneurism. New (fifth) edition. 
Edited by James C. Wilson, M. D-, Lecturer on Physical Diagnosis in the Jefferson 
Medical College, Philadelphia. In one handsome royal 12mo. volume of 274 pages, with 
12 illustrations. Cloth, $1.75. 

This little book through its various editions has 
probably done more to advance the .-science of 
physical exploration of the chest than any other 
dissertation upon the subject, and now in its fifth 
edition it is as near perfect as it can be. The 
rapidity with which previous editions were sold 
shows "how the profession appreciated the thor- 



oughness of Prof. Flint's investigations. For stu- 
dents it is excellent. Its value is shown both in 
the arrangement of the material and in the clear, 
concise style of expression. For the practitioner 
it is a ready manual for reference.— North Ameri- 
can Practitioner, January, 1891. 



B Y THE SAME A UTHOR. 

A Practical Treatise on the Physical Exploration of the Chest and 
the Diagnosis of Diseases Affecting the Respiratory Organs. Second and 
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. 

Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and 
Complications, Fatality and Prognosis, Treatment and Physical Diag- 
nosis ; In a series of Clinical Studies'. In one octavo volume of 442 pages. Cloth, $3.50. 

A Practical Treatise on the Diagnosis, Pathology and Treatment of 
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume 
of 550 pages, with a plate. Cloth, $4. 

Essays on Conservative Medicine and Kindred Topics. In one very hand- 
some royal 12mo. volume of 210 pages. Cloth, $1.38. 

BROWNE, LENNOX, F. R. C. 8., E., 

Senior Physician to the Central London Throat and Ear Hospital. 

A Practical Guide to Diseases of the Throat and Nose, including 
Associated Affections of the Ear. New (third) and enlarged edition. In one 
imperial octavo volume of 734 pages, with 120 illustrations in color, and 235 engravings 
on wood. Cloth, $6.50. 

of experience, Mr. Browne has found to be of the 
greatestutilityindiagnosisandtreatment; they are 
most simple, inexpensive and easily kept aseptic — 
points of much importance. We have on a former 
occasion eulogised the beautiful and typical col- 
ored plates drawn on stone by the author-artist 
himself, and forming in themselves a valuable 
and instructive atlas, the equal of which is not to 
be found in any modern work, treating of these 
subjects. Mr. Lennox Browne is to congratulated 
on having produced the best practical text-book 



The third edition of Mr. Lennox Browne's in- 
structive and artistic work on " The Throat and 
Its Diseases" appears under the title of "The 
Throat and Nose and Their Diseases." This 
change has been rendered desirable by the ad- 
vances made during the last decade in rhino! ogy. 
The nasal sections, which extend to upwards of 
100 pages, give in a short space the best account 
of the present position of rhinology with which 
we are acquainted. The engravings in this hand- 
some volume are of the same high order as here- 
tofore, and more numerous than ever; they can- | on diseases of the throat and nose extant. We 
notfail to be of the greatest assistance to senior stu- i are glad to learn that it is being translated into 
dents and practitioners. The instruments, either | French and German. — The Provincial Medical 
figured or described, are those which, as the result | Journal, August 1, 1890. 



BY THE SAME A UTHOR. 

Koch's Remedy in Relation to Throat Consumption. In one octavo 
volume of 121 pages, with 45 illustrations, 4 of which are colored, and 17 charts. 
Cloth, $1.50. Just ready. 

SEILER, CARL, M. D., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 

Nose and Naso-Pharynx. Third edition. In one handsome royal 12mo. volume 
of 373 pages, with 101 illustrations and 2 colored plates. Cloth, $2.25. 

of topics and methods. The book deserves a large 



Few medical writers surpass this author in 
ability to make his meaning perfectly clear in a 
few words, and in discrimination in selection, both 



sale, especially among general practitioners— Chi- 
cago Medical Journal and Examiner, April, 1889. 



COHEN, J. SOLIS, M. !>., 

Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. 

Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and 
Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third 
edition, thoroughly revised and rewritten, with a large number of new illustrations. In 
one very handsome octavo volume. Preparing. 

GROSS, S. D., W.D., LL.D., D.C.L. Oocon., LL.I>. Cantab. 

A Practical Treatise on Foreign Bodies in the Air-passages. In one 

octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. 



Lea Brothers & Co.'s Publications — Nerv. and Ment. Dis., etc. 19 



BOSS, JAMBS, M.D., FR. C.JP., LL.I)., 

Senior Assistant Physician to the Manchester Royal Infirmary. 

A Handbook on Diseases of the Nervous System. In 

Cloth, $4.50 ; leather, $5.50. 



one octavo 



volume of 725 pages, with 184 illustrations. 

The book before us is entitled to the highest 
consideration; it is painstaking, scientific and 
exceedingly comprehensive. — New York Medical 
Journal, July 10, 1886. 

The author has rendered a great service to the 
profession by condensing into one volume the 
principal facts pertaining to neurology and nerv- 
ous diseases as understood at the present time, 
and he has succeeded in producing a work at once 
brief and practical yet scientific, without entering 
into the discussion of theorists, or burdening the 
mind with mooted questions. — Pacific Medical and 
Surgical Journal and Western Lancet, May, 1886. 

This admirable work is intended for students of 
medicine and for such medical men as have no time 



for lengthy treatises. In the present instance the 
duty of arranging the vast store of material at the 
disposal of the author, and of abridging the de- 
scription of the different aspects of nervous dis- 
eases, has been performed with singular skill, and 
the result is a concise and philosophical guide to 
the department of medicine of which it treats. 
Dr. Ross holds such a high scientific position that 
any writings which bear his name are naturally 
expected to have the impress of a powerful intel- 
lect. In every part this handbook merits the 
highest praise, and will no doubt be found of the 
greatest value to the student as well as to the prac- 
titioner. — Edinburgh Medical Journal, Jan. 1887. 



HAMILTON, ALLAJST McLANB, M. D., 

Attending Physician at the Hospital for Epileptics and Paralytics, BlackweWs Island, N. T 
Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly 
revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. 

When the first edition of this good book appeared 
we gave it our emphatic endorsement, and th« 



present edition enhances our appreciation of the 
book and its author as a safe guide to students of 
clinical neurology. One of the best and most 
critical of English neurological journals, Brain, has 



characterized this book as the best of its kind in 
any language, which is a handsome endorsement 
from an exalted source. The improvements in the 
new edition, and the additions to it, will justify its 
purchase even by those who possess the old.— 
Alienist and Neurologist, April, 1882. 



TUHB, DAJ^IBL HACK, M. T>., 

Joint Author of The Manual of Psychological Medicine, etc. 

Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action of the Imagination. New edition. 
Thoroughly revised and rewritten. In one 8vo. vol. of 467 pp., with 2 col. plates. Cloth, $3. 

method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 



It is impossible to peruse these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomena the more firmly 
has he adhered to a physiological and rational 



science a most interesting domain in psychology, 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing. — New York Medical Journal, September 6. 1884. 



GRAY, LAJS T DOW CARTBR, M.D., 

Professor of Diseases of the Mind and Nervous System in the New York Polyclinic. 

A Practical Treatise on Diseases of the Nervous System. 



Preparing. 



CLOUSTOJST, THOMAS S., M. D., F. R. C. P., L. R. C. S., 

Lecturer on Mental Diseases in the University of Edinburgh. 

Clinical Lectures on Mental Diseases. With an Appendix, containing an 
Abstract of the Statutes of the United States and of the Several States and Territories re 
lating to the Custody of the Insane. By Charles F. Folsom, M. D., Assistant Professor 
of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo volume of 541 
pages, with eight lithographic plates, four of which are beautifully colored. Cloth, $4. 

The practitioner as well as the student will ac- 
cept the plain, practical teaching of the author as a 
forward step in the literature of insanity. It is 



refreshing to find a physician of Dr. Clouston's 
experience and high reputation giving the bed- 
side notes upon which his experience has been 
founded and his mature judgment established. 
Such clinical observations cannot but be useful to 



the general practitioner in guiding him to a diag- 
nosis and indicating the treatment, especially in 
many obscure and doubtful cases of mental dis- 
ease. To the American reader Dr. Folsom's Ap- 
pendix adds greatly to the value of the work, and 
will nuke it a desirable addition to every library. 
—American Psychological Journal, July, 1884. 



Jg^^Dr. Folsom's Abstract may also be obtained separately in one octavo volume of 
108 pages. Cloth, $1.50. 

SAVAGE, GBORGB H., M. D., 

Lecturer on Mental Diseases at Ouy's Hospital, London. 

Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol. 

of 551 pages, with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, page 81. 

As a handbook, a guide to the practitioner and I carefully selected, and as regards treatment sound 
student, the book fulfils an admirable purpose, common sense is everywhere apparent. Dr. Sav- 
The many forms of insanity are described With age has written an excellent manual for the prac- 
charactenstic clearness, the illustrative cases are | titioner and student— Amer.Jour. ofpisan., Apr.'So. 

PLAYFAIR, W. S^~AL I>., F. R. C. JP. 

The Systematic Treatment of Nerve Prostration and Hysteria. In 

one handsome small 12mo. volume of 97 pages. Cloth, $1.00. 



BLANDFORD ON INSANITY AND ITS TREAT- 
MENT. Lectures on the Treatment, Medical 
and Legal, of Insane Patients. Inoneverv hand- 
some octavo volume. 



JONES' CLINICAL OBSERVATIONS ON FUNC- 
TIONAL NERVOUS DISORDERS, Second 
American Edition. In one handsome 

volume of 340 pages. Cloth, $3.-cS. 



20 



Lea Brothers & Co.'s Publications — Surgery. 



BOBEBT8, JOHN B., M. B., 

Professor of Anatomy and Surgery in the Philadelphia Polyclinic. Professor of the Principles and 
Practice of Surgery in the Woman's Medical College of Pennsylvania. Lecturer in Anatomy in the Univer- 
sity of Pennsylvania. 

The Principles and Practice of Modern Surgery. For the use of Students 
and Practitioners of Medicine and Surgery. In one very handsome octavo volume of 780 



pages, with 501 illustrations. Cloth, $4.50, 
In this work the author has endeavored to give 
to the profession in a condensed form the doctrines 
and procedures of Modern Surgery. He has made 
it a work devoted more especially to the practice 
-than to the theory of surgery. His own large 
experience has added many valuable features to 
>the work. It contains many practical points in 
diagnosis, which render it the more valuable to 
■the practitioner; and the systematization which 
,pervades the whole work, together with its 
perspicuity, enhance its value as a s-tudent's 
manual. The fact that this work is eminently 
practical cannot be too strongly emphasized. It 
is modern, and as its teaching is that generally 
accepted and such that affords little opportunity 
for discussion, it will be lasting. It is clear and 
•concise, yet full. The book is entitled to a place 



leather, $5.50. Just ready. 
in modern surgical literature.— Annals of Surgery, 
Jan. 1891. 

This work is a very comprehensive manual upon 
general surgery, and wilf doubtless meet with a 
favorab'e reception by the profession. It, has a 
thoroughly practical character, the subjects are 
treated with rare judgment, its conclusions are in 
accord with those of the leading practitioners of 
the art, and its literature is fully up to all the ad- 
vanced doctrines and methods of practice of the 
present day. Its general arrangement follows 
this rule, and the author in his desire to be con- 
cise and practical is at times almost dogmatic, but 
this is entirely excusable considering the admira- 
ble manner in which he has thus increased the 
usefulness of his work. — Medical Record, Jan. 17, 
1891. 



A8MBJJB8T, JOSW, Jr., M. B., 

Barton Prof, of Surgery and Clin. Surgery in Univ. of Penna., Surgeon to the Penna. Hosp., etc. 

The Principles and Practice of Surgery. New (fifth) edition, enlarged 
and thoroughly revised. In one large and handsome octavo volume of 1144 pages, with 
642 illustrations. Cloth, $6 ; leather, $7. 

This is one of the most popular and useful of 
the many well-known treatises on general surgery. 
It furnishes in a concise manner a clear and 
comprehensive description of the modes of prac- 
tice now generally employed in the treatment of 
surgical affections, with a plain exposition of the 
principles on which those modes of practice are 
based. The entire work has been care fully revised, 
and a number of new illustrations introduced 
that greatly enhance the value of the book. — 
Cincinnati Lancet-Clinic, Dec. 14, 1889. 



A complete and most excellent work on surgery. 
It is only necessary to examine it to see at once 
its excellence and real merit either as text-book 
for the student or a guide for the general practi- 
tioner. It fully considers in detail every surgical 
injury and disease to which the body is liable, and 
every advance in surgery worth noting is to be 
found in its proper place. It is unquestionably the 
best and most complete single volume on surgery, 
in the English language, and cannot but receive 
that continued appreciation which its merits justly 
demand. — Southern Practitioner, Feb. 1890. 



BBUITT, BOBEBT, 3B B. C. 8., etc. 

Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- 
ley Boyd, M. B., B. S., F. R. C. S. In one 8vo. volume of 965 pages, with 373 illustra- 
tions. Cloth, $4 ; leather, $5. 



It is essentially a new book, rewritten from be- 
ginning to end. The editor has brought his work 
up to the latest date, and nearly every subject on 
which the student and practitioner would desire 
to consult a surgical volume, has found its place 
here. The volume closes with about twenty pages 
of formulae covering a broad range of practical 
therapeutics. The student will find that the new 
Druitt is to this generation what the old one was 
to the former, and no higher praise need be 
accorded to any volume.— North Carolina Medical 
Journal, October, 1887. 



Druitt's Surgery has been an exceedingly popu- 
lar work in the profession. It is stated that 50,000 
copies have been sold in England, while in the 
United States, ever since its first issue, it has been 
used as a text- book to a very large extent. Dur- 
ing the late war in this country it was so highly 
appreciated that a copy was issued by the Govern- 
ment to each surgeon. The present edition, while 
it has the same features peculiar to the work at 
first, embodies all recent discoveries in surgery, 
and is fully up to the times. — Cincinnati Medical 
News, September, 1887. 



GANT, FBEBEBICK JAMES, F. B. C. 8., 

Senior Surgeon to the Royal Free Hospital, London. 
The Student's Surgery. A Multum in Parvo. In one square octavo volume 
of 848 pages, with 159 engravings. Cloth, $3.75. 

GBO88, S. B., M. B., LB. D. 9 B. C. L. Oxon., LB. £>. 
Cantab., 

Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. 
A System of Surgery : Pathological, Diagnostic, Therapeutic and Operative. 
Sixth edition, thoroughly revised and greatly improved. In two large and beautifully 
printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. 
Strongly bound in leather, raised bands, $15. 

BABE, CBLABLES B., 31. Ch., Bub., F. B. C. 8., E., 

Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. 

Diseases of the Hectum and Anus. In one 12mo. volume of 417 pp., 
with 54 cuts, and 4 colored plates Cloth, $2.25. See Series of Clinical Manuals 31. 

GIBWET, Y. B., 31. B., 

Surgeon to the Orthopaedic Hospital, New York, etc. 
Orthopaedic Surgery. For the use of Practitioners and Students. In one hand- 
some octavo volume, profusely illustrated. Preparing. 



Lea Brothers & Co.'s Publications — Surgery. 



21 



S., 



JERICHSEN, JOHN E., F. R. S., F. R. C. 

Professor of Surgery in University College, London, etc. 
The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- 
eases and Operations. From the eighth and enlarged English edition. In two large and 
beautiful octavo volumes of 2316 pages, illustrated with 984 engravings on wood. 
Cloth, $9; leather, raised bands, $11. 

We have always regarded "The Science and 
Art of Surgery" as one of the best surgical text- 
books in the English language, and this eighth 
edition only confirms our previous opinion. We 
take great pleasure in cordially commending it to 
our readers.— The Medical News, April 11, 1885. 

For many years this classic work has been 
made by preference of teachers the principal 
text-book on surgery for medical students, while 



through translations into the leading continental 
languages it may be said to guide the surgical 
ieachings of the civilized world. No excellence 
of the former edition has been dropped and no 
discovery, device or improvement which has 
marked the progress of surgery during the last 
decade has been omitted. The illustrations are 
many and executed in the highest style of art. 
—Louisville Medical News, Feb. 14, 1885. 



BRYANT, THOMAS, F. R. C. S., 

Surgeon and Lecturer on Surgery at Guy's Hospital, London. 
The Practice Of Surgery. Fourth American from the fourth and revised Eng- 
lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 
727 illustrations. Cloth, $6.50; leather, $7.50. 



The fourth edition of this work is fully abreast 
•of the times. The author handles his subjects 
with that degree of judgment and skill which is 
■attained by years of patient toil and varied ex- 
perience. The present edition is a thorough re- 
vision of those which preceded it, with much new 
.matter added. His diction is so graceful and 
logical, and his explanations are so lucid, as to 
place the work among the highest order of text- 
cooks for the medical student. Almost every 
'topic in surgery is presented in such a form as to 



enable the busy practitioner to review any subject 
in every-day practice in a short time. No time is 
lost with useless theories or superfluous verbiage. 
In short, the work is eminently clear, logical and 
practical. — Chicago Medical Journal and Examiner, 
April, 1886. 

This book is essentially what it purports to be, 
viz.: a manual for the practice of surgery. It is 
peculiarly well fitted for the student or busy general 
practitioner.— The Medical News, August 15, 1885. 



TREVES, FREDERICK, F. R. C. S., 

Hunterian Professor at the Royal College of Surgeons of England. 
A Manual of Surgery. In Treatises by Various Authors. In three 12mo. 
Tolumes, containing 1866 pages, with 213 engravings. Price per volume, cloth, $2. See 
Students' Series of Manuals, page 31. 



We have here the opinions of thirty-three 
•authors, in an encyclopaedic form for easy and 
ready reference. The three volumes embrace 
•every variety of surgical affections likely to be 
tmet with, the paragraphs are short and pithy, and 



the salient points and the beginnings of new sub- 
jects are always printed in extra-heavy type, so 
that a person may find whatever information he 
may be in need of at a moment's glance.— Cin- 
cinnati Lancet-Clinic, August 21, 1886. 



HOLMES, TIMOTHY, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A System of Surgery ; Theoretical and Practical. IN TREATISES BY 
VARIOUS AUTHORS. American edition, thoroughly revised and re-edited 
by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, 
Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. 
In three large imperial octavo volumes containing 3137 double- columned pages, with 
979 illustrations on wood and 13 lithographic plates, beautifully colored. Price per 
;aet, cloth, $18.00 ; leather, $21.00. Sold only by subscription. 

WHARTON, HENRY R., M. D., 

Demonstrator of Surgery and Lecturer on Surgical Diseases of Children in the Un v. of Penna. 

Minor Surgery and Bandaging. In one very handsome 12mo. volume of 
498 pages, with 403 engravings, many being photographic. Cloth, $3.00. Just ready. 

MARSH, HOWARD, F. R. C. S., 

Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew'' s Hospital, London. 
Diseases of the Joints. In one 12mo. volume of 468 pages, with 64 woodcuts 
and a colored plate. Cloth, $2.00. See Series of Clinical Manuals, page 31. 

BUTLIN, HENRY^., F. R. C. 8., 

Assistant Surgeon to St. Bartholomew's Hospital, London. 
Diseases of the Tongue. In one 12mo, volume of 456 pages, with S colored 
plates and 3 woodcuts. Cloth, $3.50. See Series of Clinical Manuals, page 31. 

TREVES, FREDERICK, F. R. C. S., 

Surgeon to and Lecturer on Surgery at the London Hospital. 

Intestinal Obstruction." In one pocket-size 12mo. volume of 522 pages, with 60 
-illustrations. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 31. 

GOULD, A. FEARCE, M. S., 31. B., F R. C. S., 

Assistant Surgeon to Middlesex Hospital. 

Elements of Surgical Diagnosis. In one pocket-size 12mo. volume o( 589 
(pages. Cloth, $2.00. See Students' Scries of Manuals, page 31. 



SPIRRIE'S PRINCIPLES AND PRACTICE OF 
SURGERY. Edited by John Neill, M. D. In 
one 8vo. vol. of 784 pp. with 816 illus. Cloth, $3.75. 

MILLER'S PRINCIPLES OF SURGERY. Fourth 
American from the third Edinburgh edition. In 



one Svo. vol. of 63S pasjes, with 340 illustrations. 
Oloth,$3.76. 
MILLER'S PRACTICE OF SURGERY. Fourth 
and revised American edition. In one large Br** 
vol. of 682 pp., with 864 illustrations. Cloth ,$3.75. 



22 Lea Brothers & Co.'s Publications — Surgery, Frac, Disloc. 



SMITH, STEPHEN, M. H., 

Professor of Clinical Surgery in the University of the City of New York. 

The Principles and Practice of Operative Surgery. New (second) and 
thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 
1005 illustrations. Cloth, $4.00; leather, $5.00. 



This excellent and very valuable book is one of 
the most satisfactory works on modern operative 
surgery yet published. Its author and publisher 
have spared no pains to make it as far as possible 
an ideal, and their efforts have given it a position 
prominent among the recent works in this depart- 
ment of surgery. The book is a compendium for 
the modern surgeon. The present, the only revised 
edition since 1879, presents many changes from 
the original manual. The volume is much en- 
larged, and the text has been thoroughly revised, 
so as to give the most improved methods in asep- 



tic surgery, and the latest instruments known for 
operative work. It can be truly said that as a hand- 
book for the student, acompanion for the surgeon, 
and even as a book of reference for the physician 
not especially engaged in the practice of surgery, 
this volume will long hold a most conspicuous 
place, and seldom will its readers, no matter how 
unusual the subject, consult its pages in vain. Its 
compact form, excellent print, numerous illustra- 
tions, and especially its decidedly practical char- 
acter, all combine to commend it. — Boston Medical 
and Surgical Journal, May 10, 1888. 



HOLMES, TIMOTHY, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A Treatise on Surgery; Its Principles and Practice. New American 
from the fifth English edition, edited by T. Pickering Pick, F. E. C. S. In one octavo 
volume of 997 pages, with 428 illustrations. Cloth, $6.00 ; leather, $7.00. 

To the younger members of the profession and for the general practitioner, teaching those things 
to others not acquainted with the book and its that are necessary to be known for the successful 



merits, we take pleasure in recommending it as a 
surgery complete, thorough, well-written, fully 
illustrated, modern, a work sufficiently volumi- 
nous for the surgeon specialist, adequately concise 



prosecution of the physician's career, imparting 
nothing that in our present knowledge is. consid- 
ered unsafe, unscientific or inexpedient.— Pacific 
Medical Journal, July, 1889. 



HAMILTON, FRANK H., M. D., LL. J>., 

Surgeon to Bellevue Hospital, New Fork. 

A Practical Treatise on Fractures and Dislocations. New (8th) edi- 
tion, revised and edited by Stephen Smith, A. M., M. D., Professor of Clinical Surgery 
in the University of the City of New York. In one very handsome octavo volume of 832 
pages, with 507 illustrations. Cloth, $5.50 ; leather, $6.50. 

It has received the highest endorsement that a 
work upon a department ot surgery can possibly 
receive. It is used as a text-book in every medi 
cal college of this country, and the publishers 
have been called upon to print eight editions of it. 
What more can be said in commendation of it? 
It has been said with truth that ic is doubtful if 
any surgical work has appeared during the last 
half century which more completely filled the 
place for which it was- designed. As Dr. Smith 
says, its great merits appear most conspicuously 
in its clear, concise, and yet comprehensive state- 
ment of principles, which renders it an admirable 
text-book for teacher and pupil, and in its wealth 
of clinical materials, which adapts it to the daily 
necessities of the practitioner. Fractures and 
dislocations are injuries which the general practi- 



tioner, in his character as a surgeon, is most called 
upon to treat. They form a part of surgery that 
he cannot avoid taking charge of. Under the 
circumstances, therefore, he needs all the aid he 
can secure. But what better assistance can he 
seek than a work that is devoted exclusively to 
treating fractures and dislocations, and conse- 
quently contains full information, in plain lan- 
guage, for the management of every emergency 
that is likely to be met with ia such injuries? 
The country is filled with railroads and manufac- 
tories where accidents are constantly occurring, 
and to which general practitioners, and not dis- 
tinguished surgeons, are constantly liable to be 
called. We consider that the work before us 
should be in the library of every practitioner.— 
Cincinnati Medical Neivs, February, 1891. 



STIMSON, LEWIS A., B. A., M. &., 

Surgeon to the Presbyterian and Bellevue Hospitals, Professor of Clinical Surgery in the Medical 
Faculty of Univ. of City of N. Y., Corresponding Member of the Societe de Chirurgie of Paris. 
A Manual of Operative Surgery. New (second) edition. In one very hand- 
some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. 



There is always room for a good book, so that 
while many works on operative surgery must be 
considered superfluous, that of Dr. Stimson has 
held its own. The author knows the difficult art 
of condensation. Thus the manual serves as*a 
work of reference, and at the same time as a 
handy guide. It teaches what it professes, the 
steps of operations. In this edition Dr. Stimson 
has sought to indicate the changes that have been 



effected in operative methods and procedures by 
the antiseptic system, and has added an account 
of many new operations and variations in the 
steps of older operations. We do not desire to 
extol this manual above many excellent standard 
British publications of the same class, still we be- 
lieve that it contains much that is worthy of imi- 
tation. — British Medical Journal, Jan. 22, 1887. 



By the same Author. 
A Treatise on Fractures and Dislocations. In two handsome octavo vol- 
umes. Vol. I., Fractures, 582 pages, 360 beautiful illustrations. Vol. II., Disloca- 
tions, 540 pages, with 163 illustrations. Complete work, cloth, $5.50 ; leather, $7.50. 
Either volume separately, cloth, $3.00; leather, $4.00. 



The appearance of the second volume marks the 
completion of the author's original plan of prepar- 
ing a work which should present in the fullest 
manner all that is known on the cognate subjects 
of Fractures and Dislocations. The volume on 
Fractures assumed at once the position of authority 
on the subject, and its companion on Dislocations 
will no doubt be similarly received. The closing 
volume of Dr. Stimson's work exhibits the surgery 



of Dislocations as it is taught and practised by the 
most eminent surgeons of the present time. Con- 
taining the results of such extended researches it 
must for a long time be regarded as an authority 
on all subjects pertaining to dislocations. Every 
practitioner of surgery will feel it incumbent on 
him to have it for constant reference. — Cincinnati 
Medical News, May, 1888. 



PICK, T. BICKFKING, F. K. C. S., 

Surgeon to and Lecturer on Surgery at St. George's Hospital, London. 

Fractures and Dislocations. In one 12mo. volume of 530 pages, 
illustrations. Limp cloth, $2.00. See Series of Clinical Manuals, page 31. 



with 93 



Lea Brothers & Co.'s Publications — Otol., Ophtlial, 



23 



BVBNETT, C SABLES H., A. M., M. D., 

Professor of Otology in the Philadelphia Polyclinic; President of the American etiological Society. 

The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise 
for the use of Medical Students and Practitioners. Second edition. In one handsome 
octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. 

carried out, and much new matter added. Dr. 

Burnett's work must be regarded as a very valua- 



We note with pleasure the appearance of a second 
edition of this valuable work. When it first came 
out it was accepted by the profession as one of 
the standard works on modern aural surgery in 
the English language; and in his second edition 
Dr. Burnett has fully maintained his reputation, 
for the book is replete with valuable information 
and suggestions. The revision has been carefullv 



ble contribution to aural surgery, not only on 
account of its comprehensiveness, but because it 
contains the results of the careful personal observa- 
tion and experience of this eminent aural surgeon. 
—London Lancet, Feb. 21, 1885. 



BEBBY, GEOBGE A., M. B., F. B. C. 8., Ed., 

Ophthalmic Surgeon, Edinburgh Royal Infirmary. 
Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. In 
one octavo volume of 683 pages, with 144 illustrations, 62 of which are beautifully 
colored. Cloth, $7.50. 



This newest candidate for favor among ophthal- 
mological students is designed to be purely clinical 
in character and the plan is well adhered to. We 
have been forcibly struck by the rare good taste 
in the selection of what is essential which per- 
vades the book. The author seems to have the 
uncommon faculty of viewing his subject as a 
whole and seizing the salient points and not con- 
fusing his reader — presumably a student and a 



novice — with a mass of details with no key to their 
unravelling. It is apparent that the literature of 
each subject has been gone over in a very thor- 
ough manner. The fact that he was writing a 
clinical treatise for beginners and not an encyclo- 
paedia has always been present with the author. 
The number and excellence of the colored illus- 
trations in the text deserve more than a passing 
notice. — Archives of Ophthalmology, Sept. 1889. 



€/• 8», 

Surgeon to the Royal London {Moorfields) 



NETTLESHIP, EZ>WABZ>, F. B. 

Ophthalmic Surgeon at St. Thomas' Hospital, London. 
Ophthalmic Hospital. 

Diseases of the Eye. New (fourth) American from the fifth English edition, 
thoroughly revised. With a Supplement on the Detection of Color Blindness, by Wil- 
liam Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. 
In one 12mo. volume of 500 pages, with 164 illustrations, selections from Snellen's test- 
types and formulae, and a colored plate. Cloth, $2.00. 

important parts of clinical ophthalmology. A 
supplement is made to the present edition on the 
practical examination of railroad employes as to 
color-blindness and acuteness of vision and hear- 
ing. This is well written, and contains good 
suggestions for those who may be called on to 
make such examinations.— New York Medical 



This is a well-known and a valuable work. It 
was primarily intended for the use of students, 
and supplies their needs admirably, but it is as 
useful lor the practitioner, or indeed more so. It 
does not presuppose the large amount of recondite 
knowledge to be present which seems to be as- 
sumed in some of our larger works, is not tedious 
from over-conciseness, and yet covers the more 



Journal, December 13, 1890. 



JULEB, SEWBY E., F. B. C. 8., 

Senior Ass't Surgeon, Royal Westminster Ophthalmic Hosp.; laite Clinical AssH, Moorfields, London. 

A Handbook of Ophthalmic Science and Practice. Handsome 8vo. vol- 
ume of 460 pages, with 125 woodcuts, 27 colored plates, selections from Test-types of 
Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $4.50 ; leather, $5.50. 
It presents to the student concise descriptions illustrations are nearly all original. We have ex- 
and typical illustrations of all important eye affec- amined this entire work with great care, and it 
tions, placed in juxtaposition, so as to be grasped represents the commonly accepted views of ad- 
at a glance. Beyond a doubt it is the best illus- vanced ophthalmologists. We can most heartily 
trated handbook of ophthalmic science which has commend this book to all medical students, prac- 
ever appeared. Then, what is still better, these titioners and specialists. — Detroit Lancet, Jan. '85. 



FOBBIS, WM. F., M. Z>., and OLIVEB, CMA8. A. 9 M. I). 

Clin. Prof, of Ophthalmology in Univ. of Pa. 
A Text-Book of Ophthalmology. In one octavo volume of about 500 pages, 
Preparing. 



with illustrations. 



CABTEB, B. BBUDEJSTELL, & FBOST, W. ADAMS, 

F. B. C. 8., F. B. C. 8., 



Ophthalmic Surgeon to and Lect. on Ophthal- 
mic Surgery at St. George's Hospital, London. 



Ass't Ophthalmic Surgeon and Joint Led. 
on Oph. Sur., St. George's Hosp., London. 



Ophthalmic Surgery. In one 12mo. volume of 559 pages, with 91 woodcuts, 
color-blindness test, test-types and dots and appendix of formula?. Cloth, $2.25. See 
Series of Clinical Manuals, page 31. 



WELLS ON THE EYE. In one octavo volume. 

LAURENCE AND MOON'S HANDY HOOK OF 
OPHTHALMIC SURGERY, for the use of Prac- 
titioners. Second edition. In one octavo vol- 
ume of 227 pages, with 65 illus. Cloth, $2.75. 



LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS: Their Immediate and Remote 
Effects. In one octavo volume of 40-1 pages, with 
92 illustrations. Cloth, §3.50. 



24 Lea Brothers & Co.'s Publications — Urin, Dis., Dentistry, etc. 



ROBERTS, SIR WILLIAM, M. D., 

Lecturer on Medicine in the Manchester School of Medicine, etc. 

A Practical Treatise on Urinary and Renal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. In one hand- 
some octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. 



It may be said to be the best book in print on the 
subject of which it treats.— The American Journal 
of the Medical Sciences, Jan. 1886. 

The peculiar value and finish of the book are in 
a measure derived from its resolute maintenance 
of a clinical and practical character. It is an un- 
rivalled exposition of everything which relates 
directly or indirectly to the diagnosis, prognosis 
and treatment of urinary diseases, and possesses 



completeness not found elsewhere in our Ian- 

fuage in its account of the different affections. — 
''he Manchester Medical Chronicle, July, 1885. 
The value of this treatise as a guide book to th© 
physician in daily practice can hardly be over- 
estimated. That it is fully up to the level of our 
present knowledge is a fact reflecting great credit 
upon Dr. Roberts, who has a wide reputation as a 
busy practitioner.— Medical Record, July 31, 1886. 



By the Same Author. 
Diet and Digestion. In one 12mo. volume of 270 pp. Cloth, $1.50. 



Just ready. 



FURDY, CHARLES W. 9 31. I)., Chicago. 

Bright's Disease and Allied Affections of the Kidneys. In one octavo 

volume of 288 pages, with illustrations. Cloth, $2. 

short space the theories, facts and treatments, and 



The object of this work is to "furnish a system- 
atic, practical and concise description of the 
pathology and treatment of the chief organic 
diseases of the kidney associated with albuminu- 
ria, which shall represent the most recent ad- 
vances in our knowledge on these subjects ; " and 
this definition of the object is a fair description of 
the book. The work is a useful one, giving in a 



going more fully into their later developments. 
On treatment the writer is particularly strong,, 
steering clear of generalities, and seldom omit- 
ting, what text-books usually do, the unimportant 
items which are all important to the general prac- 
titioner. — The Manchester Medical Chronicle, Oct. 
1886. 



MORRIS, HE WRY, M. B., F. R. C. S., 

Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. 

Surgical Diseases of the Kidney. In one 12mo. volume of 554 pages, with 40 
woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 31. 



In this manual we have a distinct addition to 
surgical literature, which gives information not 
elsewhere to be met with in a single work. Such 
a book was distinctly required, and Mr. Morris 
has very diligently and ably performed the task 



he took in hand. It is a full and trustworthy 
book of reference, both for students and prac- 
titioners in search of guidance. The illustrations 
in the text and the chromo-lithographs are beau- 
tifully executed.— The London Lancet,Feb. 26, 1886. 



See Series 



LUCAS, CLEMENT, M. B., B. S., E. R. C. S., 

Senior Assistant Surgeon to Guy's Hospital, London. 
Diseases of the Urethra. In one 12mo. volume. Preparing, 
of Clinical Manuals, page 4. 

THOMPSON, SIR HENRY, 

Surgeon and Professor of Clinical Surgery to University College Hospital, London. 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 
On the Pathology and Treatment of Stricture of the Urethra and 
Urinary Fistulae. From the third English edition. In one octavo volume of 359 
pages, with 47 cuts and 3 plates. Cloth, $3.50. 

THE AMERICAN SYSTEM OF DENTISTRY. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., 
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- 
taining 3160 pages, with 1863 illustrations and 9 full-page plates. Per volume, cloth, $6 ; 
leather, $7 ; half Morocco, gilt top, $8. The complete work is now ready. For sale by 
subscription only. 



As an encyclopaedia of Dentistry it has no su- 

f>erior. It should form a part of every dentist's 
ibrary, as the information it contains is of the 
Greatest value to all engaged in the practice of 
entistry. — American Jour. Dent. Sci., Sept. 1886. 
A grand system, big enough and good enough 
and handsome enough for a monument (which 



doubtless it is), to mark an epoch in the history of 
dentistry. Dentists will be satisfied with it and 
proud of it — they must. It is sure to be precisely 
what the student needs to put him and keep him 
in the right track, while the profession at large 
will receive incalculable benefit from it.— Odonto- 
graphy Jomnal, Jan. 1887. 



COLEMAN, A., L. R. C. F., F. R. C. S., Exam. L. JD. S., 

Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London, 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 
adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D., 
D. D. S., Prof, of Physiology in the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, $3.25. 



It should be in the possession of every practi- 
tioner in this country. The part devoted to first 
and second dentition and irregularities in the per- 
manent teeth is fully worth the price. In fact, 
price should not be considered in purchasing such 



work. If the money put into some of our so- 
called standard text-books could be converted into 
such publications as this, much good would result. 
—Southern Dental Journal, May, 1882. 



BASH AM ON RENAL DISEASES: A Clinical 
Guide to their Diagnosis and Treatment. In 



one 12 mo. vol. of 304 pages, with 21 illusi rations. 

Cloth, $2.00. 



Lea Brothers & Co.'s Publications — Venereal, Impotence. 



25 



GROSS, SAMUEL W., A. M., 31. !>., LL. I)., 

Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Phila. 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
Of the Male Sexual Organs. New (4th) edition, thoroughly revised by F. E. 
Sturgis, M. D., Prof, of Diseases of the Genito- Urinary Organs and of Venereal Diseases, 
N. Y. Post Grad. Med. School. In one very handsome octavo volume of 1C5 pages, 
with 18 illustrations. Cloth, $1.50. 



Three editions of Professor Gross' valuable book 
have been exhausted, and still the demand is 
unsupplied. Dr. Sturgis has revised and added 
to the previous editions, and the new one appears 
more complete and more valuable than before. 
Four important and generally misunderstood sub- 
jects are trea'.ed— impotence, sterility, spermator- 
rhoea, and prostatorrhcea. The book is a practical 
one and in addition to the scientific and very in- 
teresting discussions on etiology, symptoms, etc., 
there are lines of treatment laid down that any 
practitioner can follow and which have met with 
success in the hands of author and editor.— Medi- 
cal Record, Feb. 25, 1891. 

It has been the aim of the author to supply in a 
•compact form, practical and strictly scientific 
information especially adapted to the wants of the 
general practitioner in regard to a class of common 



and grave disorders The work contains very 
many facts in regard to the sexual disorders of 
men, of the most interesting character. We com- 
mend the study of it to every professional man, 
and especially to those engaged in the general 
practice of medicine.— Cm. Med. News, Jan. 1891. 

The work before us has become a standard text- 
book on the subjects of which it treats. In the 
present edition the author's work has been con- 
siderably augmented by Dr. Sturgis, whose con- 
tributions and views are to be f-een everywhere. 
They contain many valuable suggestions an<l are 
the fruit of a ripe experience which cannot but 
enhance the original text. The profession is 
quick to appreciate succinct treatises which are 
full and complete, more especially when the 
authors are known to be worthy of respect and 
confidence. — St. Louis Med. and Su g. Jour., Feb.'91. 



TAYLOR, R. W., A. M., M. JD., 

Clinical Profes <or of Genito- Urinary Diseases in the College of Physicians and Surgeons, New York, 
Prof, of Venereal and Skin Diseases in the University of Vermont, 

The Pathology and Treatment of Venereal Diseases. Including the 
results of recent investigations upon the subject. Being the sixth edition of Bumstead 
and Taylor. Entirely rewritten by Dr. Taylor. Large 8vo. volume, about 900 pages, 
with about 150 engravings, as well as numerous chromo-lithographs. In active preparation. 

A notice of the previous edition is appended. 



It is a splendid record of honest labor, wide 
research, just comparison, careful scrutiny and 
original experience, which will always be held as 
a high credit to American medical literature. This 
is not only the best work in the English language 



upon the subjects of which it treats, but also one 
which has no equal in other tongues for its clear, 
comprehensive and practical handling of its 
themes.— Am. Jour, of the Med. Sciences, Jan. 1884. 



CULVER, E. M.. 31. D.. and HAYDE1T, J. R.. M. L>. 



Pathologist and Assistant Attending Surgeon t 
Manhattan Hospital, N. Y. 



Chief of Clinic Venereal Department, Van- 
derbilt Clinic, Coll. ofPhys and Surgs., N. Y. 

In one 12mo. volume of about 250 pages, 



A Manual of Venereal Diseases. 

with illustrations. Ready shortly. 

CORNLL, V. 9 

Professor to the Faculty of Medicine of Paris, and Physician to the Lour cine Hospital. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. Henry C. Simes, 
M. D., Demonstrator of Pathological Histology in the Univ. of Pa., and J. William 
White, M. D., Lecturer on Venereal Diseases, Univ. of Pa. In one handsome octavo 
volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. 

perusal without the feeling that his grasp of the 
wide and important subject on which it treats is 
a stronger and surer one. — The London Practi- 
tioner, Jan. 1882. 



The anatomy, the histology, the pathology and 
the clinical features of syphilis are represented in 
this work in their best, most practical and most 
instructive form, and no one will rise from its 



HTJTCHLNSON, JONATHAN, F. R. S., F. R. C. S., 

Consulting Surgeon to the London Hospital. 
Syphilis. In one 12mo. volume of 542 pages, with 8 chromo-lithographs. Cloth, 
$2.25. See Series of Clinical Manuals, page 31. 



Those who have seen most of the disease and 
those who have felt the real difficulties of diagno- 
sis and treatment will most highly appreciate the 
facts and suggestions which abound in these 
pages. It is a worthy and valuable record, not 



only of Mr. Hutchinson's very large experience | 



and power of observation, but of his patience and 
assiduity in taking notes of his cases and keep- 
ing them in a form available for such excellent 
use as he has put them to in this volume.— London 
Medical Record, Nov. 12, 1S87. 



GROSS, S. JD., M. L>., LL. L>., JD. C. L., etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
-edition, thoroughly revised by Samuel W. Gross, M. D. In one octavo volume oi 574 
pages, with 170 illustrations. Cloth, $4.50. 

CULLERIER, A., & BU3ISTEAI), F. J., M.I)., LL. D.. 

Surgeon to the Hdpital du Midi. Late Prof, of Ven. Dis. Coll. Phys. and Sura., N. Y. 

An Atlas of Venereal Diseases. Translated and edited by Freeman J. Bum- 
stead, _M.D. In one imperial 4to. volume of 32S pages, double-columns, with 26 plates, 
containing about 150 figures, beautifully colored, many of them the size o( life. Strongly 
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of '2-3 cts 

H i L T ^i )N sy PHILIS AND LOCAL CONTAGIOUS I FORMS OF LOCAL DISEASE AFFECTING 

DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. PRINCIPALLY THE ORGANS OF GENERA- 

LEE'S LECTURES ON SYPHILIS AND SOME TION. In one 8vo. vol. of 846 pages. Cloth | ; "- 



26 



Lea Brothers & Co.'s Publications — Venereal, Skin. 



TAYLOR, ROBERT W., A.M., M.I)., 

Clinical Professor of Genifo Urinary Diseases in the College of Physicians and Surgeons, New York ; 
Surgeon to the Department of Venereal and Skin Diseases of the New York' Hospital; Presi- 
dent of the American Dermatological Association. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis, 
Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and 
comprising 58 beautifully colored plates with 213 figures, and 431 pages of text with 85 
engravings. Complete work just ready. Price per part, $2.50. Bound in one volume, 
half Russia, $27 ; half Turkey Morocco, §28 For sale by subscription only. Specimen 
plates sent on receipt of 10 cents. A full prospectus sent to any address on application 



The completion of this monumental work is 
subject of congratulation, not only to the author 
and publishers, but to the profession at large ; 
indeed it is to the latter that it directly appeals as 
a wonderfully clear exposition of a confessedly 
difficult branch of medicine Good literature has 
joined hands with good art with highty satisfac- 
tory results for both. There are altogether 213 
figures, many of which are life size, and represent 
the highest perfection of the chromo-litho- 
graphic art, and scattered throughout the text are 
innumerable engravings. Quite a proportion of 
these illustrations are from the author's own 
collection, while on the other hand the best 
atlases of the world have been drawn upon for 
the most typical and successful pictures of the 
many different types of venereal and skin dis 
ease. We think we may say without undue 
exaggeration that the reproductions, both in color 
and in black and white, are almost invariably 
successful. The text is practical, full of thera- 
peutical suggestions, and the clinical accounts of 
disease are clear and incisive. Dr. Taylor is, 
happily, an eminent authority in both departments, 



allotted to a notice of this kind, and while we 
have nothing but praise for this admirable atlas, 
it must be said in justification that it is more than 
warranted by the merits of the work itself.— 

The Medical News, Dec. 14, 1889. 

It would be hard to use words which would per- 
spicuously enough convey to the reader the great 
value of this Clinical Atlas. This Atlas is more 
complete even than an ordinary course of clinical 
lectures, for in no one college or hospital course 
is it at all probable that all of the diseases herein 
represented would be seen. It is also more ser- 
viceable to the majority of students than attend- 
ance upon clinical lectures, for most of the 
students who sit on remote seals in the lecture 
hall cannot see the subject as well as the office 
studentcan examine these true to-life ehromo-lith- 
ographs. Comparing the text to a lecturer, it is 
more satisfactory in exactness and fulness than 
he would be likely to be in lecturing over a single 
ease. Indeed, this Atlas is invaluable to the gen- 
eral practitioner, for it enables the eye of the 
physician to make diagnosis of a given case of 

kin manifestation by comparing the case with 



and'we find as a consequence that the two divis- the picture in the Atlas, where will be found also 
ions of this work possess an equal scientific and the text of diagnosis, pathology, and full sections 
literary merit. We have already passed the limits | on treatment. — Virginia Medical Monthly, Dec. 1889. 



HYDE, J. JSTEVFFS, A. M., M. D., 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 
Practitioners. New (second) edition. In one handsome octavo volume of 676 pages, 
with 2 colored plates and 85 beautiful and elaborate illustrations. Cloth, $4.50; leather, $5.50. 



We can heartily commend it, not only as an 
admirable text-book for teacher and student, but 
in its clear and comprehensive rules for diagnosis, 
its sound and independent doctrines in pathology, 
and its minute and judicious directions for the 
treatment of disease, as a most satisfactory and 
complete practical guide for the physician. — Ameri- 
can Journal of the Medical Sciences, July, 1888. 

A useful glossary descriptive of terms is given. 
The descriptive portions of this work are plain 
and easily understood, and above all are very 
accurate. The therapeutical part is abundantly 
supplied with excellent recommendations. The 
picture part is well done. The value of the work 
to practitioners is great because of the excellence 
of the descriptions, the suggestiveness of the 
advice, and the correctness of the details and the 
principles of therapeutics impressed upon the 
reader.— Virginia Med. Monthly, May, 1888. 



The second edition of his treatise is like his 
clinical instruction, admirably arranged, attractive 
in diction, and strikingly practical throughout. 
The chapter on general symptomatology is a model 
in its way; no clearer description of the various 
primary and consecutive lesions of the skin is to 
be met with anywhere. Those on general diagno- 
sis and therapeutics are also worthy of careful 
study. Dr. Hyde has shown himself a compre- 
hensive reader of the latest literature, and has in- 
corporated into his book all the best of that which 
the past years have brought forth. The prescrip- 
tions and formulae are given in both common and 
metric systems. Text and illustrations are good, 
and colored plates of rare cases lend additional 
attractions. Altogether it is a work exactly fitted 
to the needs of a general practitioner, and no one 
will make a mistake in purchasing it. — Medical 
Press of Western New York, June, 1888. 



FOX, T., M. D., F.R. C. P., and FOX, T. C, B.A., M.R. C.S., 

Physician for Diseases of the Skin to the 
Westminster Hospital, London. 

An Epitome of Skin Diseases. With Formulae. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one 12mo. vol. of 238 pp. Cloth, $1.25. 
The third edition of this convenient handbook I manual to lie upon the table for instant reference. 



Physician to the Department for Skin Diseases, 
University College Hospital, London. 



calls for notice owing to the revision and expansion 
which it has undergone. The arrangement of skin 
diseases in alphabetical order, which is the method 
of classification adopted in this work, becomes a 
positive advantage to the student. The book is 
one which we can strongly recommend, not only 
to students but also to practitioners who require a 
compendious summary of the present state of 
dermatology.— British Medical Journal, July 2, 1883. 
We cordially recommend Fox's Epitome to those 
whose time is limited and who wish a handv 



Its alphabetical arrangement is suited to this use, 
for all one has to know is the name of the disease, 
and here are its description and the appropriate 
treatment at hand and ready for instant applica- 
tion. The present edition has been very carefully 
revised and a number of new diseases are de- 
scribed, while most of the recent additions to 
dermal therapeutics find mention, and the formu 
Jary at the end of the book has been considerably 
augmented.— The Medical News, December, 1883. 



WILSOX, ERASMUS, F. R. S. 

The Student's Book of Cutaneous Medicine and Diseases of the Skin. 

In one handsome small octavo volume of 535 pages. Cloth, $3.50. 



HILLIER'S HANDBOOK OF SKIN DISEASES; 
for Students and Practitioners. Second Ameri- 



can edition, 
with plates. 



In one 12mo. volume of 353 pages, 
Cloth, $2.25. 



Lea Brothers & Co.'s Publications — Dis. of Women. 



27 



The American Systems of Gynecology and Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics 
and Gynecology in the Medical Department of the University of Buffalo; and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the 
University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- 
taining 3612 pages, 1092 engravings and 8 plates. Complete work now ready. Per vol- 
ume: Cloth, |5.00; leather, $6.00; half Russia, $7.00. For sale by subscription only. 
Address the Publishers. Full descriptive circular free on application. 

LIST OF CONTRIBUTORS. 

WILLIAM H. BAKER, M. D., 

ROBERT BATTEY, M. D., 

SAMUEL C BUSEY, M. D., 

JAMES C. CAMERON, M. D., 

HENRY C. COE, A. M., M. L\, 

EDWARD P. DAVIS, M. D., 

G. E. De SCHWEINITZ, M. D., 

E. C. DUDLEY, A. B., M. D., 

B. McE. EMMET, M. D., 

GEORGE J. ENGELMANN, M. D., 

HENRY J. GARRIGUES, A. M., M. D., 

WILLIAM GOODELL, A. M., M. D., 

EGBERT H. GRANDIN, A. M., M. D., 

SAMUEL W. GROSS, M. D., 

ROBERT P. HARRIS, M. D., 

GEORGE T. HARRISON, M. D., 

BARTON C. HIRST, M. D. 

STEPHEN Y. HOWELL, M. D., 

A. REEVES JACKSON, A. M., M. D., 

W. W. JAGGARD, M. D., 

EDWARD W. JENKS, M. D., LL. D., 
These volumes are the contributions of the most 
eminent gentlemen of this country in these de- 
partments of the profession. Each contributor pre- 
sents a monograph upon his special topic, so that 
everything in the way of history, theory, methods, 
and results is presented to our'fullest need. As a 
work of general reference, it will be found remarka- 
bly full and instructive in every direction of 
inquiry.— The Obstetric Gazette, September, 1889. 

There can be but little doubt that this work will 
find the same favor with the profession that has 
been accorded to the " System of Medicine by 
American Authors," and the "System of Gynecol- 
ogy byAmerican Authors." One is at a loss to know 
wnat to say of this volume, for fear that just and 
merited praise may be mistaken for flattery. The 
papers of Drs. Engelmann, Martin, Hirst, Jaggard 
and Reeve are incomparably beyond anything that 
can be found in obstetrical works. Certainly the 
Editor may be congratulated for having made such 
a wise selection of his contributors.— Journal of 
theAmericar Medical Association, Sept. 8, 1888. 

In our notice of the "System of Practical Medi- 
cine by American Authors," we made the follow- 
ing statement :— " It is a work of which the pro- 



HOWARD A. KELLY, M. D , 
CHARLES CARROLL LEE, M. D., 
WILLIAM T. LUSK, M. D., LL. D., 
J. HENDRIE LLOYD, M. D., 
MATTHEW D. MANN, A. M., M. D., 
H. NEWELL MARTIN, F. R. S., M. D., 
RICHARD B. MAURY, M. D., 
C. D. PALMER, M. D., 
ROSWELL PARK, M. D., 
THEOPHILUS PARVIN, M. D., LL. D., 
R. A. F. PENROSE, M. D., LL. D., 
THADDEUS A. REAMY, A. M., M. D., 
J. C. REEVE, M. D., 
A. D. ROCKWELL, A. M., M. D., 
ALEXANDER J. C. SKENE, M. D., 
J. LEWIS SMITH, M. D., 
STEPHEN SMITH, M. D., 
R. STANSBURY SUTTON, M. D.. LL.D., 
T. GAILLARD THOMAS, M. D., LL. D., 
ELY VAN DE WARKER, M. D, 
W. GILL WYLIE, M. D. 
fession in this country can feel proud. Written 
exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 
United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 
ers of medicine, and it seems to us that every one 
of them would desire to have it." Every word 
thus expressed in regard to the "American Sys- 
tem of Practical Medicine" is applicable to the 
"System of Gynecology by American Authors." 
It, like the other, has been written exclusively 
by American physicians who are acquainted with 
all the characteristics of American people, who are 
well informed m regard to the peculiarities of 
American women, their manners,_ customs, modes 
of living, etc. As every practising physician is 
called upon to treat diseases of females, and as 
they constitute a class to which the family phy= 
sician must give attention, and cannot pass over 
to a specialist, we do not know of a work in any 
department of medicine that we should so strongly 
recommend medical men generally purchasing.— 
Cincinnati Med. News, July,1887. 



THOMAS, T. GAILLAIZD, and MVNJDB, PAUL F., 

31. D., LL. !>., 31. L>., 

Professor of Diseases of Women in the College Professor of Gynecology in the New York 

of Physicians and Surgeons, N. Y. Polyclinic. 

A Practical Treatise on the Diseases of Women. New (sixth) edition, 
thoroughly revised and rewritten by Dr. Munde. In one large and handsome octavo 
volume of about 900 pages, with over 300 illustrations. Beady shortly. 

Dr. Thomas' standard work in the original text and by its translations into other 
languages is everywhere regarded as the best representative of the peculiarly American 
science of gynecology. In this revision the joint authors have undertaken to preserve the 
practical nature of the work which has rendered it so useful to students and physicians, 
and also to bring it abreast with the best gynecological views and practice of the present 
day. The thorough character of the revision can be understood from the fact that of the 
illustrations one hundred and seventy-five are new. 

EL> IS, AKTLTUtt W., 31. D., Land., F.JR. C. J\, 31. JR. C. 8. 9 

Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. 
The Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome 
octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00; leather, $4.00. 

among the more common methods of treat* 



The special qualities which are conspicuous 
are thoroughness in covering the whole ground, 
clearness of description and' conciseness ot state 
ment. Another marked feature of the book is 
the attention paid to the details of many minor 
surgical operations and procedures, as, for 
instance, the use of tents, application of leeches, 
and use of hot water injections. These are 



ment, and yet very little is said about them in 
many of the text-books. The book is one to be 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete rtsumt of the whole subject. Specialists, too, 
will find many useful hints "in its pages.— 
Med. and Surg'. Jown., March 'J, 1882. 



28 



Lea Brothers & Co.'s Publications — Dis. of Women, Midwfy. 



EMMET, THOMAS ADDIS, M. D. 9 LL. D., 

Surgeon to the Woman's Hospital, New York, etc. 

The Principles and Practice of Gynaecology ; For the use of Students and 
Practitioners of Medici ne. New (third) edition, thoroughly revised. Id one large and very 
handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5; leather, $6;, 
very handsome half Eussia, raised bands, $6.50. 

the privilege thus offered them of perusing the 
views and practice of the author. His earnestness^ 
of purpose and conscientiousness are manifest. 



We are in doubt whether to congratulate the 
author more than the profession upon the appear- 
ance of the third edition of this well-known work. 
Embodying, as it does, the life-long experience of 
one who has conspicuously distinguished himself 
as a bold and successful operator, and who has 
devoted so much attention to the specialty, we 
feel sure the profession will not fail to appreciate 



He gives not only his individual experience but 
endeavors to represent the actual state of gynse- 
cological science and art.— British Medical Jour- 
nal, May 16, 1885. 



TAIT, LA WSON, F. B. C. S., 

Professor of Gynaecology in Queen? s College, Birmingham ; late President of the British Gym* 
cological Society ; Fellow American Gynecological Society. 

Diseases of "Women and Abdominal Surgery. In two very handsome 
octavo volumes. Volume I., 554 pages, 62 engravings and 3 plates. Cloth, $3. New 
ready. Volume II., preparing. 



The plan of the work does not indicate the regu- 
lar system of a text book, and yet nearly every- 
thing of disease pertaining to the various organs 
receives a fair consideration. The description of 
diseased conditions is exceedingly clear, and the 
treatment, medical or surgical, is very satisfactory. 



Much of. the text is abundantly illustrated with 
cases, which add value in showing the results of 
the suggested plans of treatment. We feel con- 
fident that few gynecologists of the country will 
fail to place the work in their libraries. — The 
Obstetric Gazette, March, 1890. 



DAVEWPOBT, F. H., M. D., 

Assistant in Gynaecology in the Medical Department of Harvard University, Boston. 

Diseases of Women, a Manual of Non-Surgical Gynaecology. De- 
signed especially for the Use of Students and General Practitioners. In one handsome 
12mo. volume of 317 pages, with 105 illustrations. Cloth, $1.50. 



We agree with the many reviewers whose no- 
tices we have read in other journals congratulating 
Dr. Davenport on the success which he has 
attained. He has tried to write a book for the 
student and general practitioner which would 
tell them just what they ought to know without 
distracting their attention with a lot of compila- 
tions for which they could have no possible use. 
In this he has been eminently successful. There 
is not even a paragraph of useless matter. 



Everything is of the newest, freshest and moat 
practical, so much so that we have recommended- 
it to our class of gynecology students. What the 
author advises in the way of treatment has all 
been practically tested by himself, and each 
method receives only so much commendation as he 
has found that it deserves. We are sure that 
these good qualities will command for it a large- 
sale. — Canada Medical Record, Dec. 1889. 



MAY, C SABLES H., M. D., 

Late House Surgeon to Mount Sinai Hospital, New York. 
A Manual of theDiseases of Women. Being a concise and systematic expo- 
sition of the theory and practice of gynecology. New (2d) edition, edited by L. S. Kauy 
M. D., Attending Gynecologist at the Harlem Hospital, N. Y. In one 12mo. volume of 
360 pages, with 31 illustrations. Cloth, $1.75. Just ready. 



This is a manual of gynecology in a very con- 
densed form, and the fact that a second edition 
has been called for indicates that it has met with 
a favorable reception. It is intended, the author 
tells us, to aid the student who after having care- 
fully perused larger works desires to review the 
subject, and he adds that it may be useful to the 
practitioner who wishes to refresh his memory 



rapidly but has not the time to consult larger 
works. We are much struck with the readiness^ 
and convenience with which one can refer to any 
subject contained in this volume. Carefully com- 
piled indexes and ample illustrations also enrich 
the work. This mauual will be found to fulfil its 
purposes very satisfactorily.— The Physician and- 
Surgeon, June, 1890. 



DVNCAjy, J. MATTHEWS, M.D., LL. D., F. B. S. E., etc. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

rule, adequately handled in the text-books; others 
of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a* 



They are in every way worthy of their author ; 
indeed, we look upon them as among the most 
valuable of his contributions. They are all upon 
matters of great interest to the general practitioner. 
Some of them deal with subjects that are not, as a 



stamp of individuality that they deserve to be 
widely read.— N. Y. Medical Journal, March, 1880. 



HODGE ON DISEASES PECULIAR TO WOMEN. 
Including Displacements of the Uterus. Second 
edition, revised and enlarged. In one beauti- 
fully printed octavo volume of 519 pages, with 
original illustrations. Cloth, $4.60. 

RAMSBOTHAM'S PRINCIPLES AND PRAC- 
TICE OF OBSTETRIC MEDICINE AND 
SURGERY. In reference to the Process of 
Parturition. A new and enlarged edition, thor- 
oughly revised by the Author. With additions 
by W. V. Keating, M. D., Professor of Obstt tries, 



etc., in the Jefferson Medical College of Phila- 
delphia. In one large and handsome imperial 
octavo volume of 640 pages, with 64 full page 
plates and 43 woodcuts in the text, containing in, 
all nearly 200 beautiful figures. Strongly bound 
in leather, with raised bands, $7. 
WEST'S LECTURES ON THE DISEASES OF~ 
WOMEN Third American from the third Lon- 
don edition. In one octavo volume of 543 pages.. 
Cloth, $3.75; leather, $4.75. 



Lea Brothers & Co.'s Publications — Midwifery, 



29» 



PARVIJST, THEOFSILVS, M. JD., LL. JD., 

Prof, of Obstetrics and the Diseases of Women and Children in Jefferson Med. Coll., Phila. 

The Science and Art of Obstetrics. New (2d) edition. In one handsome 
8vo. volume of 701 pages, with 239 engravings and a colored plate. Cloth, $4.25; leather^ 
$5.25. 



The second edition of this work is fully up to the 
present state of advancement of the obstetric art. 
The author has succeeded exceedingly well in 
incorporating new matter without apparently in- 
creasing the size of his work or interfering with 
the smoothness and grace of its literary construc- 
tion. He is very felicitous in his descriptions of 
conditions, and proves himself in this respect a 
scholar and a master. Rarely in the range of 



obstetric literature can be found a work which is 
s-o comprehensive aad yet compact and practical.. 
In such respect it is essentially a text book of the 
first merit. The treatment of the subjects gives a 
real value to the work— the individualities of a. 
practical teacher, a skilful obstetrician, a close 
thinker and a ripe scholar. — Medical Record, Jan, 
17, 1891. 



PZATFAIR, W. S., M. JD., F. R. C. P., 

Professor of Obstetric Medicine in King's College, London, etc. 

A Treatise on the Science and Practice of Midwifery. New (fifth, 

American, from the seventh English edition. Edited, with additions, by Robert P. Har- 
ms, M. D. In one handsome octavo volume of 664 pages, with 207 engravings and 5- 
plates. Cloth, $100 ; leather, $5.00. 



Truly a wonderful book; an epitome of all ob- 
stetrical knowledge, full, clear and concise. In 
thirteen years it has reached seven editions. It 
is perhaps the most popular work of its kind ever 
presented to the profession. Beginning with the 
anatomy and physiology of the organs concerned, 
nothing is left unwritten that the practical ac- 
coucheur should know. It seems that every 
conceivable physiological or pathological condi- 



tion from the moment of conception to the time 
of complete involution has had the author's 
patient attention. The plates and illustrations,., 
carefully studied, will teach the science of mid- 
wifery. The reader of this book will have before 
him the very latest and best of obstetric practice., 
and also of all the coincident troubles connected 
therewith.— Southern Practitioner, Dec. 1889. 



KING, A. F. A., M. JD., 

Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer~ 
sity, Washington, D. C, and in the University of Vermont, etc. 

A Manual of Obstetrics. New (fourth) edition. In one very handsome 12mo. 
volume of 432 pages, with 140 illustrations. Cloth, $2.50. 



Dr. King, in the preface to the first edition of 
this manual, modestly states that "its purpose is 
to furnish a good groundwork to the student at 
the beginning of his obstetric studies." Its pur- 
pose is attained; it will furnish a good ground- 
work to the student who carefully reads it; and 
further, the busy practitioner should not scorn the 
volume because written for students, as it con- 
tains much valuable obstetric knowledge, some 
of which is not found in more elaborate text- 
books. The chapters on the anatomy of the 
female generative organs, menstruation, fecunda- 
tion, the signs of pregnancy, and the diseases of 
pregnancy, are all excellent and clear; but it is in 



the description of labor, both normal and abnor- 
mal, that Dr. King is at his best. Here his style 
is so concise, and the illustrations are so good,, 
that the veriest tyro could not fail to receive a clear 
conception of labor, its complications and treat- 
ment. Of the 141 illustrations it may be safely 
said that they all illustrate, and that the engraver's- 
work is excellent. The name of the publishers 
is a sufficient guarantee that the work is pre- 
sented in an attractive form, and from every 
standpoint we can most heartily recommend the 
book both to practitioner and student. — The Medi- 
cal News, Dec. 7, 1889. 



BARNES, ROBERT, M. D., and FANCOURT, 31. JD., 

Phys. to the General Lying-in Hosp., Load. Obstetric Phys. to St. Thomas' LTosp., Lond. 

A System of Obstetric Medicine and Surgery, Theoretical and Clin- 
ical. For the Student and the Practitioner. The Section on Embryology by Prof. Milnes 
Marshall. In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5 ; leather, $6. 

The immediate purpose of the work is to furnish 
a handbook of obstetric medicine and surgery 
for the use of the student and practitioner. It is 
not an exaggeration to say of the book that it is 
the best treatise in the English language yet 
published, and this will not be a surprise to those 
who are acquainted with the work of the elder 
Barnes. Every practitioner who desires to have 



the best obstetrical opinions of the time in a 
readily accessible and condensed form, ought to 
own a copy of the book. — Journal of the American 
Medical Association, June 12, 1886. 

The Authors have made a text-book which is ii> 
every way quite worthy to take a plac^ beside the 
best treatises of the period. — New York I 
Journal, July 2, 1887. 



WINCKEL, F. 

A Complete Treatise on the Pathology and Treatment of Childbed, 

For Students and Practitioners. Translated, with the consent of the Author, from the 
second German edition, by J. E. Chadwick, M. D. Octavo 484 pages. Cloth, #4.00. 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 
American from the third and revised London 
edition. In one 8vo. vol., pp. 520. Cloth. $3.50. 

PARRY ON EXTRA-UTERINE PREGNANCY: 
Its Clinical History, Diagnosis, Prognosis and 
Treatment. Octavo, 272 pages. Cloth, $2,50, 



TANNER ON PREGNANCY. Octavo, 400 pages,, 
colored plates, 16 cuts. Cloth, 84.25 

CHURCHILL ON THE PUERPERAL EEYER 
AND OTHER DISEASES PECULIAR TO W 
MEN. In one 8VO. vol. of 464 pages. Cloth, $2.: 

MEIGS ON THE NATURE. SIGNS AND TREAT- 
MENT OF CHILDBED FEYER. In one 8vt. 
volume of 346 patens. Cloth, $2.00. 



30 Lea Brothers & Co/s Publications — Midwfy., Dis. Childn, 



SMITH, J. LEWIS, M. &., 

(Ji.inical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. T. 

A Treatise on the Diseases of Infancy and Childhood. New (seventh) 
edition, thoroughly revised and rewritten. In one handsome octavo volume of 881 
pages, with 51 illustrations. Cloth, $4.50 ; leather, $5.50. Just ready. 

Every department shows that it has been thor- l children, the work of Dr. J. Lewis Smith easily 
ong dy revised, and that every advantage has been ! holds a front pla?e. lis several editions have all 
taken'of recent advance in knowledge to bring it been thoroughly revised. In the present one we 
completely up to the times. "What makes the work notice that many of the chapters have been en- 
of Dr. Smith of especial value is the attention paid tirely rewritten. Full notice is taken of all the 
to diagnosis and the careful detail of treatment, 'recent advances that have been made. As its 
It is undoubtedly one of the best treatises on j author states in the preface, the necessary revision 
children's diseases, and as a text-book for students ; has virtually produced anew work. In the amount 
and guide for young practitioners it is unsurpassed. ; of information presented the work may properly 
—I ff-Uo Medical and Surgical Journal, Jan. 1891- I be considered to have doubled in size, but by 

Already in previous editions the work of Dr. condensation and the exclusion of all obsolete 
Smith held position undisputed at the head of its i material the volume has not been rendered incon- 
class. No book in any language could dispute j veniently Jarge. Many diseases not previously 
with it the title to pre-eminence. A list of works treated of have received special chapters. The 
on diseases of children, made up in any country, | work is a very practical one. Especial care has 
would have this work at its head, and for the pur- i been taken that the directions for treatment shall 
poses of the great majority of practitioners the I be particular and full. In no other work are such 
list would be complete with this one alone. — Araeri- | careful instructions given in the details of infant 
tan Practitioner and News, May 9, IS I hygiene and the artificial feeding of infants.— 

Notwithstanding the many excellent volumes ! Montreal Medical Journal, Feb. 1891. 
that have been issued recently on diseases of 



LEISH3IAJS T , WILLIAM, 31. D., 

Regius Professor of Midwifery in the University of Glasgow, Wtc. 

A System of Midwifery, Including the Diseases of Pregnancy and the 
Puerperal State. Fourth edition. Octavo. 

LAXDIS, MEXBY G., A. M., M. I)., 

Professor of Obstetrics and the Diseases of Women in Starling Medical College, Coluvibus, 0. 

The Management of Labor, and of the Lying-in Period. In one 

handsome 12mo. volume of 334 pages, with 28 illustrations. Cloth, $1.75. 

The author has designed to place in the hands tempt any one who should happen to commence 
of the young practitioner a book in which he can the book to read it through. The author pre- 
find necessary information in an instant. As far , supposes a theoretical knowledge of obstetrics, 



as we can see, nothing is omitted. The advice is 
sound, and the procedures are safe and practical. 
Cent Ublatt fur Gynakologie, December 4, 1886. 

This is a book we can neartiiy recommend. 
The author goes much more practically into the 
details of the management of labor than most 
text-books, and is so readable throughout as to 



and has consistently excluded from this little 
work everything that is not of practical use in the 
lying-in room. We think that if it is as widely 
read as it deserves, it will do much to improve 
obstetric practice in general. — New Orleans Medi- . 
cal and Surgical Journal, Liar. 1886. 



OWEN, EJD3IUJSD, 31. B., F. B. C. S., 

Surgeon to the Children's Hospital, Great Ormond St., London. 

Surgical Diseases of Children. In one 12mo. volume of 525 pages, with 4 
chromo-lithographic plates and 85 woodcuts. Cloth, $2. See Series of Clinical 31 'an uals, 
page 31. 

One is immediately struck on reading this book ; honestly recommended to both students and 
with its agreeable style and the evidence it every- j practitioners. It is full of sound information, 
where presents of the practical familiarity of its I pleasantly given. — Annals of Surgery, May, 1886. 
author with his subject. The book may be j 



STUDENTS' SEBIES OF 3IAXLALS. 

A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, 
written by eminent Teachers or Examiners, and issued in pocket-size 12mo volumes of 300-540 pages, 
richly illustrated and at a low price. The following volumes are now ready: Teeves' Manual of Sur- 
ge y. by various writers, in three volumes, eacb, $2; Bell's Comparative Physiology and Anatomy, $2; 
G-oule's Surgical Diagnosis. §2; Robertson's Physiological Physics, $2; Beuce's Materia Medicaand Thera~ 
: (4th edition). 81.50; Power's Human Physiology (2d edition), $1.50; Clarke and Lockwood's 
Dissectors* Manual, 51.50; Ralfe's Clinical Chemistry," $1.50; Treves' Surgical Applied Anaton 
Pepper's Surgical Pathology, $2 ; and Klein's Elements of Histology (4th edition), $1.75. The following 
is in press ; Pepper's Forensic Medicine. For separate notices see index on last page. 



SEBIES OF CLINICAL 3IAJTUALS. 

In arranging for this Series it has been the design of the publishers to provide the profession with 
a collection of authoritative monographs on important clinical subjects in a cheap and portable form. 
The volumes will contain about 550 pages and will be freely illustrated by chromo-lithographs and wood- 
cucs. The following volumes are now ready: Yeo on Food in Health and Disease, $2; Beoadbent on 
the Pulse. $1.75: Cabteb & Feost's Ophthalmic Surgery, 82.25; Hutchinson on Syphilis, $2.25; Ball on 
the Rectum and Anus, $2.25; Marsh on the Joints, $2; Owen on Surgical Diseases of Children, ?2; 
is on Surgical Diseases of the Kidney, $2.25; Pick on Fractures and Dislocations', §2; Butlix on 
the Tongue, $3.50; Treves on Intestinal Obstruction, $2; and Savage on Insanity and Allied Neuroses, $2. 
The following is in active preparation: Lxcas on Diseases of the Urethra. For separate notices see 
index on last page. 

CONDIE'S PRACTICAL TREATISE OX THE I WEST ON SOME DISORDERS OF THE NERV- 
DISEASES OF CHILDREN. Sixth edition, re- | OUS SYSTEM IN CHILDHOOD. In one small 

and augmented. In one octavo volume of ! 12mo. volume of 127 pages. Cioth,$1.00. 
779 pages. Cloth, $5.25 ; leather, $6.25. 



Lea Brothers & Co.'s Publications — Med. Juris., Miscel. 31 



TIDY, CSAMLES MEYMOTT, M. B., F. C. S., 

Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc. 

Legal Medicine. Volume II. Legitimacy and Paternity, Pregnancy, Abor- 
tion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, 
Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc- 
tavo volume of 529 pages. Cloth, $6.00 ; leather, $7.00. 

Volume I. Containing 664 imperial octavo pages, with two beautiful colored 
plates. Cloth, $6.00; leather, $7.00. 



The satisfaction expressed with the first portion 
of this work is in no wise lessened by a perusal of 
the second volume. We find it characterized by 
the same fulness of detail and clearness of ex- 
pression which we had occasion so highly to com- 
mend in our former notice, and which render it so 
valuable to the medical jurist. The copious 



tables of cases appended to each division of the 
subject must have cost the author a prodigious 
amount of labor and research, but they constitute 
one of the most valuable features of the book, 
especially for reference in medico-legal trials.— 
American Journal of the Medical Sciences, April, 1884. 



TAYLOtt, AJLFBEJ) 8., M. D., 

Lecturer on Medical Jurisprudence and Chemistry in G-uy 's Hospital, London. 

Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition. In one large octavo volume of 788 
Cloth, $5.50; leather, $6.50. 



By the Same Author. 
A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- 
don edition, thoroughly revised and rewritten. Edited by John J. Reese, M. D. 
large octavo volume. 



m one 



, F. n. a s., 

Preparing. See Students' 



PEPFEM, AUGUSTUS J., M. S., M. B, 

Examiner in Forensic Medicine at the University of London. 

Forensic Medicine. In one pocket-size 12mo. volume. 
Series of Manuals, below. 

LEA, SEJSTMY €., LL. JD. 

Chapters from the Religious History of Spain.— Censorship of the 
Press.— Mystics and Illuminati.— The Endemoniadas— El Santo Nino 
de la Guardia. — Brianda de Bardaxi. In one 12mo. volume of 522 pages. 
Cloth, $2.50. Just ready. 



The width, depth and thoroughness of research 
which have earned Dr. Lea a high European place 
as the ablest historian the Inquisition has yet 
found are here applied to some side-issues of that 
great subject. We have only to say of this volume 
hat it worthily complements the author's earlier 
tudies in ecclesiastical history. His extensive 
and minute learning, much of it from inedited 
manuscripts in Mexico, appears on every page. — 

ondon Antiquary, Jan. 1891. 

After attentively reading the work one does not 
know whether the author is a Catholic, a Protestant 



or a free-thinker. This moderation deprives the 
indictment of none of its force. The facts and 
the documents, of which the number and novelty 
attest a patient erudition, are grouped in luminous 
order and produce on the reader an effect all the 
more powerful in that it seems the less designed. 
When we add that the style is in every way ei eel- 
lent, that it is clear, sober and precis'e, we do full 
justice to a work which reflects the highest honor 
on the talents of the writer and on the method of 
the modern school of history .—Revue Critique 
d'Histoire et de Literature, Paris, Jan. 1891. 



By the same Author. 
Superstition and Force : Essays on The "Wager of Law, The Wager of 
Battle, The Ordeal and Torture. Third revised and enlarged edition. In one 
handsome royal 12mo. volume of 552 pages. Cloth, $2.50. 

Mr. Lea's curious historical monographs, of 

hich one of the most important is here produced 
in an enlarged form, have given him a unique 
position among English and American scholars. 
He is distinguished for his recondite and affluent 
learning, his power of exhaustive historical analy- 



sis, the breadth and accuracy of his researches- 
among the rarer sources of knowledge, the gravity 
and temperance of his statements, combined with 
singular earnestness of conviction, and his warm 
attachment to the cause of freedom and intellect- 
ual progress. — N. Y. Tribune, August 9, 1S7S. 



By the Same Author. 
Studies in Church History. The Rise of the Temporal Power— Ben- 
efit of Clergy— Excommunication— The Early Church and Slavery. Sec- 
ond and revised edition. In one royal octavo volume of 605 pages. Cloth, $2.50. 

shown such research, accuracy and grasp in 
investigating important and out-of the-way 
connected with the history of Europe in the Mid- 
dle Ages.— N. Y. Times. 
It is some years since we read the first edition 



The author is preeminently a scholar; he takes 
up every topic allied with the leading theme and 
traces it out to the minutest detail with a wealth 
of knowledge and impartiality of treatment that 
compel admiration. The amount of information 
compressed into the book is extraordinary, and 
the profuse citation of authorities and references 
makes the work particularly valuable to the student 
who desires an exhaustive review from original 
sources. In no other single volume is the develop- 
ment of the primitive church traced with so much 
clearness and with so definite a perception of 
complex or conflicting forces.— -Boston Traveller. 

Mr. Lea is facile prineeps among American 
scholars in the history of the Middle Ages, and, 
indeed, we know of no European writer who has 



of this work by Mr. Lea, and the impression 

by it on us at the time is confirmed by reperusal 

oi it in this enlarged and improved form : namely, 
that it is a book of great research and accuracy, 
full of varied information on very interesting 
phases of church life and history. It discusses 
each subject with a rare fulness of dates and in- 
stances, and a curious conscientiousness of veri- 
fication and citation of authorities 
Scotsman, 



Allen's Anatomy . ... 6 

American Journal of the Medical Sciences . 3 

American Systems of Gynecology and Obstetrics 27 

American System of Practical Medicine . . 15 

American System of Dentistry - . .24 

Ashhurst's Surgery 

Ashwell on Diseases of Women 

Attfield's Chemistry 

Ball on the Rectum and Anus 

Barlow's Practice of Medicine . 17 

Barnes' Svstern of Obstetric Medicine . . 29 

Bartholow on Electricity .... 17 

Basham on Penal Diseases .... 24 

Bell's Comparative Physiology and Anatomy 

Bellamy's Surgical Anatomv ... 6 

Berry on the Eye ..... 23 

Billings' National Medical Dictionary . . 4 

Biandford on Insanity . . . .19 

Bloxam's Chemistry 

Bristowe's Practice of Medicine 

Broadbent on the Pulse . . . . 16, 30 

Browne on Koch's Remedy . ... 18 

Browne on the Throat, Nose and Ear . . IS 

Bruce's Materia Medica and Therapeutics . 12,30 

Brunton's Materia Medica and Therapeutics . 11 

Bryant's Practice of Surgery . . . .21 

Bumstead and Taylor on Venereal. See Taylor. 25 

Burnett on the Ear . 23 

Butlin on the Tongue . .. 21,30 

Carpenter on the Use and Abuse of Alcohol 

Carpenter's Human Physiology ... 8 

Carter & Frost's Ophthalmic Surgery . .23,30 

Chambers on Diet and Regimen ... 17 

Chapman's Human Physiology 

Charles' Physiological and Pathological Chem. 10 

Churchill on Puerperal Fever 

Clarke and Lockwood's Dissectors' Manual . 6,30 

Classen's Quantitative Analysis ... 10 

Cleland's D ssector . .... 6 

Clouston on Insanity . ... 19 

Clowes' Practical Chemistry ... 10 

Coats' Pathology .... 13 

Cohen on the Throat .... 18 

Cohen's Applied Therapeutics . . .12 

Coleman's Dental Surgery .... 24 

Condie on Diseases of Children 

Cornil on Syphilis ..... 25 

Culver & Hayden on Venereal Diseases . . 25 

Dalton on the Circulation .... 7 

Dalton's HumanPhvsiology 

Davenport on Diseases of Women . . . 28 

Davis' Clinical Lectures . . .17 

Draper's Medical Physics 

Druitt's Modern Surgery . . 20 

Duncan on Diseases of Women . .28 

Dungllson's Medical Dictionary ... 5 

Edes' Materia Medica and Therapeutics . 12 

Edis on Diseases of Women .... 27 

Ellis' Demonstrations of Anatomy 

Emmet's Gynaecology . 28 

Erichsen's Svstem of Surgery . . .21 

Farquharson's Therapeutics and Mat. Med. . 12 

Finlayson's Clinical Diagnosis ... 16 

Flint on Auscultation and Percussion . . 18 

Flint on Phthisis ..... 18 

Flint on Respiratory Organs ... IS 

Flint on the Heart . ... 18 

Flint's Essays . .... 18 

Flint's Practice of Medicine . . .14 

Folsom's Laws of TJ. S. on Custody of Insane . 19 

Foster's Phvsiologv 

Fotnergill's Handbook of Treatment . . 16 

Fownes' Elementary Chemistry ... 9 

Fox on Diseases of the Skin .... 26 

Frankland and Japp's Inorganic Chemistry . 9 

Fuller on the Lungs and Air Passages . . 17 

Gant's Student's Surgerv . . .20 

•Gibbes' Practical Pathology ... 13 

Gibney's Orthopaedic Surgery ... 20 

Gould's Surgical Diagnosis. . 

Gray's Anatomy . . . 

Gray on Nervous Diseases 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Griffith's Universal Formulary 

Gross on Foreign Bodies in Air-Passages 

Gross on Impotence and Sterility . 

Gross on Uriuary Organs 

Gross System of Surgery 

Habershon on the Abdo'men 

Hamilton on Fractures and Dislocations 

Hamilton on Nervous Diseases 

Hare's Practical Therapeutics 

Hare's System of Practical Tl 



Therapeutics 
Hartshorne's Anatomy and Physiology . 
Hartshorne's Conspectus of the Med. Sciences 
Hartshorne's Essentials of Medicine 
Hermann's Experimental Pharmacology 
Hill on Syphilis ..... 
Hillier's Handbook of Skin Diseases 
Hirst & Piersol on Human Monstrosities 
Hoblyn's Medical Dictionary 
Hodge on Women 

Hoffmann and Power's Chemical Analysis 
Holden's Landmarks .... 
Holland's Medical Notes and Reflections 
Holmes' Principles and Practice of Surgery 
Holmes' System of Surgery 
Horner's Anatomy and Histology 
Hndson on Fever 
Hutchinson on Syphilis 



21,30 
5 
19 
9 
13 
12 
IS 
25 
25 
20 
16 
22 
19 
11 
11 



10, 



Hyde on the Diseases of the Skin . 

Jones (C. Handheld) on Nervous Disorders 

Juler's Ophthalmic Science and Practice 

King's Manual of Obstetrics . 

Klein's Histology 

Landis on Labor 

La Roche on Pneumonia, Malaria, etc. . 

La Roche on Yellow Fever . 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye, Orbit and Eyelid 

Lea's Chapters from Religious History ot Spai 

Lea's Studies in Church History 

Lea's Superstition and Force 

Lee on Syphilis . . 

Lehmanh's Chemical Physiology . 

Leishman's Midwifery 

Lucas on Diseases of the Urethra . . . .24, 

Ludlow's Manual of Examinations 

Lyons on Fe\ er . 

Maisch's Organic Materia Medica . 

Marsh on the Joints . . .21 

May on Diseases of Women . 

Medical News ..... 

Medical News Visiting List . 

Medical News Physicians' Ledger . 

Meigs on Childbed Fever . . - 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Morris on Diseases of the Kidney . . .24, 

National Dispensatory 

National Medical Dictionary 

Neill and Smith's Compendium of Med. Sci. 

Nettleship on Diseases of the Eye . 

Norris and Oliver on the Eye 

Owen on Diseases of Children 

Parrish's Practical Pharmacy 

Parry on Extra-Uterine Pregnancy 

Parvin's Midwifery . ... 

Pavy on Digestion and its Disorders 

Payne's General Pathology . 

Pepper's System of Medicine 

Pepper's Forensic Medicine . 

Pepper's Surgical Pathology 

Pick on Fractures and Dislocations 

Pirrie's System of Surgery . 

Plavfair on Nerve Prostration and Hysteria 

Playfair's Midwifery . . • . 

Power's Human Physiology . 

Purdyon Bright's Disease and Allied Affections 

Ralfe's Clinical Chemistry 

Ramsbotham on Parturition 

Remsen's Theoretical Chemistry . 

Reynolds' System of Medicine 

Richardson's Preventive Medicine 

Roberts on Diet and Digestion 

Roberts on Urinary Diseases 

Roberts" Compend of Anatomy 

Roberts' Surgery 

Robertson's Physiological Physics 

Ross on Nervous Diseases 

Savage on Insanity, including Hysteria . . 19 

Schafer's Essentials of Histology, 

Schreiber on Massage . 

Seiler on the Throat, Nose and Naso-Pharynx 

Senn's Surgical Bacteriology 

Series of Clinical Manuals 

Simon's Manual of Chemistry 

Slade on Diphtheria .... 

Smith (Edward) on Consumption . 

Smith (J. Lewis) on Children 

Smith's Operative Surgery 

Stille on Cholera 

Stilie & Maisch's National Dispensatory 

Stille's Therapeutics and Materia Medica 

Stimson on Fractures and Dislocations 

Stimson's Operative Surgery 

Students' Series of Manuals . 

Sturges' Clinical Medicine 

Tait's Diseases of Women and Abdom. Surgery 

Tanner on Signs and Diseases of Pregnancy 

Tanner's Manual of Clinical Medicine . 

Taylor's Atlas of Venereal and Skin Diseases 

Taylor on Venereal Diseases 

Taylor on Poisons .... 

Taylor's Medical Jurisprudence 

Thomas on Diseases of Women 

Thompson on Stricture 

Thompson on Urinary Organs 

Tidy's Legal Medicine .... 

Todd on Acute Diseases ... IT 

Treves' Manual of Surgery . . . . -->.3< 

Treves' Surgical Applied Anatomy . • 6 ' 3t 

Treves on Intestinal Obstruction . . . 2],3C 

Tuke on the Influence of Mind on the Body . IS 

Vaughan & Novy's Ptomaines and Leucomained V 

Visiting List, The Medical News . . . 'c 

Walshe on the Heart . . . .17 

Watson's Practice of Physic . ... 14 

Wells on the Eye . . . . .23 

West on Diseases of Women ... 23 

West on Nervous Disorders in Childhood . »■ 

Wharton's Minor Surgery and Bandaging 

Williams on Consumption .... 

Wilson's Handbook of Cutaneous Medicine 

Wilson's Human Anatomy .... 

Winckel on Pathol, and Treatment of Childbed 

Wohler's Organic Chemistry 

Woodhead's Practical Pathology . 

Year-Books of Treatment for 1S86, '37, '89 and '90 

Yeo on Food in Health and Disease . . 17, 



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